
Book -\~\% . 



Copyrights \ c \\ \ 



COPYRIGHT DEPOSIT. 



THE DISEASES OF INFANCY 
AND CHILDHOOD 



6/ THE 



DISEASES OF INFANCY 
AND CHILDHOOD 



L. E 



FOR THE USE OF STUDENTS 
AND PRACTITIONERS OF MEDICINE 

BY 

liMMETT HOLT, M.D., Sc.D., LLD. 



PROFESSOR OF DISEASES OF CHILDREN IN THE COLLEGE OF PHYSICIANS AND SURGEONS 

(COLUMBIA UNIVERSITY), NEW YORK J ATTENDING PHYSICIAN TO THE BABIES* 

AND FOUNDLING HOSPITALS, NEW YORK ; CORRESPONDING MEMBER OF 

THE GESELLSCHAFT FUR INNERE MEDIZIN UND KINDERHEILKUNDE, 

VIENNA, AND HONORARY MEMBER OF THE GESELLSCHAFT 

FUR KINDERHEILKUNDE, GERMANY 

ASSISTED BY 

JOHN HOWLAND, A.B., M.D. 

PROFESSOR OF DISEASES OF CHILDREN IN WASHINGTON UNIVERSITY, ST. LOUIS; 

LATE ASSOCIATE IN DISEASES OF CHILDREN IN THE COLLEGE OF 

PHYSICIANS AND SURGEONS, NEW YORK 




SIXTH EDITION, FULLY REVISED 



WITH TWO HUNDRED AND FORTY ILLUSTRATIONS 
INCLUDING EIGHT COLOURED PLATES 



NEW YORK AND LONDON 

D. APPLETON AND COMPANY 

19 1 1 



/IT 

A 



Copyright, 1897, 1902, 1905, 1907, 1909, 1911, 
By D. APPLETON AND COMPANY 



PRINTED AT THE APPLETON PRESS 
NEW YOKK, U. S. A. 



^CLA295302 



TO 
VIRGIL P. GIBNEY, M.D., LL.D., 

PROFESSOR OF ORTHOPEDIC SURGERY IN THE COLLEGE OF PHYSICIANS AND 

SURGEONS (COLUMBIA UNIVERSITY), NEW YORK; SURGEON-IN-CHIEF 

TO THE HOSPITAL FOR THE RUPTURED AND CRIPPLED, 

THIS VOLUME IS INSCRIBED 

AS A TRIBUTE TO HIS PERSONAL WORTH AND HIGH PROFESSIONAL ATTAINMENTS, 
AND IN GRATEFUL REMEMBRANCE OF MANY ACTS OF KINDNESS 

BY THE AUTHOR. 



PREFACE TO THE SIXTH EDITION. 



In the preparation of this edition the author has associated with 
him Dr. John Howland, his former assistant, who will hereafter be 
connected with the work as joint author. 

Progress along many lines in paediatrics has been rapid during the 
last two years. To make room for new knowledge without unduly 
enlarging the size of the volume has made it necessary to cut out about 
seventy-five pages of old material. It is believed that this has been 
accomplished without impairing the value of the chapters which have 
been abridged. The decision of the publishers to make entirely new 
plates has made this comparatively easy. 

There is scarcely a page in the book which has not been subject to 
some revision. Many articles have been entirely rewritten and several 
new ones appear for the first time in this edition. The greater part of 
the new material will be found in the chapters upon Nutrition and 
Infant Feeding, Infant Mortality, Intestinal Intoxication, Pyloric Ste- 
nosis, Appendicitis, Acute Peritonitis, Endocarditis and Pericarditis, 
Cerebro-spinal and Other Forms of Acute Meningitis, Acute Poliomye- 
litis, Hereditary Syphilis and Tuberculosis. 

A number of the old illustrations have been omitted as no longer 
necessary; others have been replaced by better ones. In all, thirty-six 
new illustrations have been introduced, including twelve radiographs. 
All illustrations are from original sources unless otherwise stated. 

The authors desire to acknowledge their indebtedness to Dr. F. H. 
Bartlett for much assistance rendered in every way in the work of 
revision; to Dr. H. H. Mason for correction of the proof sheets, and 
to Dr. N. C. Holt for the preparation of the index. 

14 West Fifty-fifth Street, 
New York. 



TABLE OF CONTENTS. 



PART I. 

CHAPTER PAGE 

I. — Hygiene and General Care of Infants and Young Children . 1 
Care of the newly-born child ; bathing ; clothing ; care of the eyes ; 
care of the mouth and teeth ; care of the skin ; care of the genital 
organs ; vaccination ; training to proper control of rectum and 
bladder ; general hygiene of the nervous system ; sleep ; exercise ; 
airing ; the nursery ; the nurse ; the amount of air space required 
by infants ; the care of premature and delicate infants ; incubators ; 
the feeding of the premature infant. 

II. — Growth and Development of the Body 15 

Weight ; height ; growth of extremities as compared with the 
trunk ; the head ; the chest ; the abdomen ; muscular development ; 
development of special senses ; speech ; dentition. 

III. — Peculiarities of Disease in Children 29 

Etiology ; symptomatology and diagnosis ; pathology ; prognosis and 
infant mortality ; prophylaxis ; therapeutics. 



PART II. 

Section I. — Diseases of the Newly Born. 

I. — Asphyxia . 68 

II. — Congenital Atelectasis 73 

III. — Icterus 76 

IV. — The Acute Infections of the Newly Born 80 

The acute pyogenic diseases ; ophthalmia ; tetanus ; epidemic hemo- 
globinuria ; fatty degeneration of the newly born ; pemphigus. 

V. — Haemorrhages 94 

Traumatic or accidental haemorrhages ; spontaneous haemorrhages. 

VI. — Birth Paralyses 104 

Cerebral paralysis ; facial paralysis ; paralysis of the upper 
extremity. 

VII. — Tumours of the Umbilicus, etc 110 

Umbilical hernia ; mastitis ; intestinal obstruction ; diaphragmatic 
hernia ; sclerema ; oedema ; inanition fever. 

ix 



! TABLE OF CONTENTS. 

- noN 11. -Nutrition. 

too 
[ODl » U'KY 12 - 

; constituents and the purposes they subserve in nutrition. 
ll._r, n Infant's Dietart 127 

W.. man's milk; cow's milk: condensed milk; buttermilk; dried 
milk: kumyss; matsoon; junket, curds and whey: beef prepara- 
tions; cereals; infant foods. 

III.— Im \m In MNfl 163 

Choice of methods; breast Feeding; maternal nursing; wet-nursing; 
weaning; mixed feeding; artificial feeding. 

rv.— Feeding arm run First Yeae 209 

Healthy infants during the second year: difficult cases during the 
nd year; feeding from the third to the sixth year; feeding 
during acnte illness. 

V.— The Derangements of Nutrition 216 

Acnte inanition; malnutrition; marasmus. 

VI.— Diseases Due to Faulty Nutrition 233 

■burns : rickets. 

- tion III. — Diseases of the Digestive System. 

I.— of the Lips. Tongue, and Mouth 262 

Malformations; diseases of the lips; diseases of the tongue; 
alveolar abscess; difficult dentition; dental caries; catarrhal stoma- 
titis; herpetic stomatitis; ulcerative stomatitis; thrush; gonor- 
rheal stomatitis; syphilitic stomatitis; diphtheritic stomatitis; 
gangrenous stomatitis. 

[I.— Diseases of the Pharynx 282 

Acnte pharyngitis; nvulitis; elongated uvula; retro-pharyngeal ab- 
adenoid vegetations of the vault of the pharynx. 

III.— Di-i isze 01 the Tonsils 294 

Membranous tonsillitis; ulce.-o-membranous tonsillitis; follicular 

tonsillitis; phlegmonous tonsillitis; chronic hypertrophy of the 
tonsils. 

IV.— Di- mi; (Esophagus 304 

formations; acute oesophagitis ; retro-oesophageal abscess. 
V,— Diseases of the stomach 308 

Digestion in infancy; malformations and malpositions of the stom- 
ach; hypertrophic stenosis of the pylorus; vomiting; cyclic vomit- 
ing; gastraigia; acute gastric indigestion; acute gastritis: gastro- 
duodenitis; chronic gastric indigestion; dilatation of the stomach; 
Dicer of the stomach: tumours of the stomach; haemorrhage from 
the stomach. 

VI.— Diseases oi the Intestines 341 

Malformations and malpositions; diarrhoea; acute intestinal indi- 
on and intoxication; cholera infantum. 



TABLE OF CONTENTS. xi 

CHAPTER PAGE 

VII. — Diseases of the Intestines (continued) 365 

Acute colitis and ileo-colitis ; chronic ileo-colitis ; amoebic colitis ; 
amyloid degeneration of the intestines ; tuberculosis of the intestines 
and mesenteric lymph nodes. 

VIII. — Diseases of the Intestines (continued) 393 

Chronic intestinal indigestion ; intestinal colic ; chronic constipa- 
tion ; intussusception. 

IX. — Diseases of the Intestines (continued) 415 

Appendicitis ; intestinal worms. 

X. — Diseases of the Rectum 426 

Prolapsus ani ; fissure of the anus ; proctitis ; ischio-rectal abscess ; 
haemorrhoids ; incontinence of faeces. 

XI. — Diseases of the Liver 1 433 

Chronic family jaundice ; catarrhal jaundice ; functional disorders ; 
new growths ; acute yellow atrophy ; congestion of the liver : ab- 
scess of the liver ; cirrhosis ; amyloid degeneration ; fatty liver ; 
hydatids ; biliary calculi. 

XII. — Diseases of the Peritoneum 441 

Acute peritonitis; chronic (non-tuberculous) peritonitis; tuber- 
culous peritonitis ; ascites ; subphrenic abscess. 

Section IV. — Diseases on the Respiratory System. 

I. — Nasal Cavities 454 

Acute nasal catarrh ; chronic nasal catarrh ; chronic rhinitis ; 
epistaxis. 

II. — Diseases of the Larynx 462 

Catarrhal spasm of the larynx ; acute catarrhal laryngitis ; sub- 
mucous laryngitis ; chronic laryngitis ; new growths ; foreign bodies 
in the larynx and bronchi. 

III. — Diseases of the Lungs 472 

The peculiarities of the lungs in infancy and early childhood ; acute 
catarrhal bronchitis ; fibrinous bronchitis ; chronic bronchitis ; re- 
flex cough ; asthma. 

IV. — Diseases of the Lungs (continued) 489 

Pneumonia ; acute broncho-pneumonia. 

V. — Diseases of the Lungs (continued) 520 

Lobar pneumonia ; pleuro-pneumonia ; hypostatic pneumonia ; 
chronic broncho-pneumonia ; abscess of the lung ; gangrene of the 
lung ; acquired atelectasis ; emphysema. 

VI.— Pleurisy 549 

Dry pleurisy ; pleurisy with serous effusion ; empyema. 

Section V. — Diseases of the Circulatory System. 
I. — Peculiarities of the Heart and Circulation in Early Life . 564 
II. — Congenital Anomalies of the Heart 567 



1A1U.K OF CONTENTS. 
Acute pericarditis; chronic pericarditis with adhesions. 



Ml 

PAGE 

,,, ... .., , ,.,,, raa otb 

111 I I lili VMM I Is 



i\ 11- and \vi\iivK Disease 582 

gnanl endocarditis; myocarditis; anaemic murmurs; func- 
tional disorders of the heart : diseases of the blood-vessels. 

s \ 1. Diseases op the Urogenital System. 

I. — Till I KIM IN lM AMY AM) CHILDHOOD 598 

Cyclic or orthostatic albuminuria; hematuria; hemoglobinuria ; 

pyuria; indicanuria; acetonuria; anuria; diabetes insipidus. 
[L — diseases oi mi: Kidneys 606 

Malformations and malpositions; uric-acid infarctions; chronic 

congestion of the kidney: acute degeneration of the kidneys; acute 

diffuse nephritis; chronic nephritis; tuberculosis of the kidney; 

malignant tumours of the kidney; pyelitis— pyelo-cystitis ; renal 

calculi; traumatic hydronephrosis; perinephritis. 
[II.— Diseases of the Genital Organs 631 

Malformations; diseases of the male genitals; diseases of the 

female genitals. 

IV— Km BE8I8 641 

Vesical spasm; vesical calculi. 

3i i tion VII. — Diseases of the Nervous System. 

I. INTRODUCTORY 647 

II. — General and Functional Nervous Diseases 649 

Convulsions; tetany; laryngismus stridulus; holding-breath spells; 
epilepsy; chorea; other spasmodic affections; hysteria; headaches; 
disorders of speech; disorders of sleep; injurious habits of infancy 
and childhood. 

111. — Diseases "i the Brain and Meninges 694 

Malformations; pachymeningitis ; cerebro-spinal meningitis; acute 
meningitis from other causes; tuberculous meningitis; chronic 
basilar meningitis in infants; thrombosis of the sinuses of the dura 
mater; cerebral abscess; cerebral tumour; hydrocephalus; infantile 
cerebral paralysis; mental defects; chondrodystrophy ; sporadic 
cretinism; insanity; the stigmata of degeneration; deaf-mutism. 

IV. — Diseases <>i the Spinal Cord 772 

Malformations; spinal meningitis; myelitis; compression-myelitis; 
a.m.- poliomyelitis; tumours of the spinal cord; syringo-myelia ; 
Friedreich's ataxia; Landry's paralysis ; the muscular atrophies. 

V. — Diseases oi the Peripheral Nerves 800 

Multiple neuritis; diphtheritic paralysis; facial paralysis. 

\ III. Diseases of the Blood, Lymph Nodes, Bones, etc. 

[.—Diseases oi the Blood 809 

■imple anaemia; chlorosis; pseudo-leukgemic anaemia 
fancy; pernicious anaemia; leukaemia; hemophilia; purpura. 



TABLE OF CONTENTS. xiii 

CHAPTER PAGE 

II. — Diseases of the Lymph Nodes 830 

Status lymphaticus ; simple acute adenitis ; simple chronic adenitis ; 
syphilitic adenitis ; tuberculous adenitis ; Hodgkin's disease. 

III. — Diseases of the Spleen 848 

IV. — Diseases of the Bones and Joints 850 

Acute arthritis of infants ; tuberculous diseases of the bones and 
joints ; syphilitic diseases of bone. 

V. — Diseases of the Skin 875 

Congenital ichthyosis ; miliaria ; seborrhoea ; eczema ; furunculosis ; 
gangrenous dermatitis ; impetigo contagiosa ; urticaria ; scabies ; 
tinea tonsurans. 

VI. — Acute Otitis 894 

Section IX. — The Specific Infectious Diseases. 

I. — Scarlet Fever 903 

II. — Measles 927 

III. — Rubella . . . . ' 943 

IV. — Varicella . 946 

V. — Vaccinia — Vaccination 948 

VI. — Pertussis 954 

VII. — Mumps 965 

VIII. — Diphtheria and Intubation . 969 

IX. — Typhoid Fever 1009 

X. — Tuberculosis 1017 

XL — Syphilis 1052 

XII. — Influenza 1070 

XIII. — Malaria 1075 

Section X. — Other General Diseases. 

I. — Rheumatism 1085 

II. — Diabetes Mellitus 1091 



LIST OF ILLUSTRATIONS. 



PLATES. FACING 

PLATE PAGE 

I. Chart showing by months the mortality of New York City for the 

different ages for three years 43 

II. Meningeal haemorrhage in the newly born 104 

III. Chart showing composition of various infant foods compared with 

woman's milk 163 

IV. Bone in rickets 246 

V. Typical rickets 248 

VI. Deformity of the chest in severe rickets 252 

VII. The stomach at the different periods of infancy 308 

VIII. Extensive superficial ulceration of the colon 368 

IX. Deep follicular ulcers of the colon 370 

X. Membranous inflammation of the ileum 372 

XI. Acute broncho-pneumonia 494 

XII. Acute pleuro-pneumonia 538 

XIII. Chronic broncho-pneumonia 540 

XIV. Acute meningitis, complicating pleuro-pneumonia . . . .718 
XV. The blood in leukaemia and pernicious anaemia, etc 810 

XVI. Eruption of measles 932 

XVII. The pathognomonic sign of measles (Koplik's spots) . . . 940 

XVIII. The diphtheritic membrane 973 

XIX. Tuberculosis of the tracheo-bronchial lymph nodes .... 1028 



ILLUSTRATIONS IN THE TEXT. 

FIGURE PAGE 

1. Breck's feeding tube 13 

2. Scales 15 

3. Weight curve for the first twenty days 16 

4. Weight curve for the first year 17 

5. Skull, showing premature ossification 23 

6. Deaths, New York City, per 1,000 of population 43 

7. Deaths by months, New York City 43 

8. Chief causes of death first year 44 

9. Nasal syringe 58 

10. Position for nasal syringing ... 59 

11. Croup kettle 60 

12. Apparatus for stomach-washing . 61 

xv 



xvi LIST OV [ILLUSTRATIONS. 

PIOl kv: PAGE 

13. Position for stomach-washing 62 

14. Colon of ;i child six months old 64 

15. Carrel's apparatus for inflating the lungs 73 

16. Pemphigus Neonatorum 93 

17. Triple cephalhematoma 96 

ib's paralysis 109 

l!>. Umbilical fistula and tumours Ill 

20. Diaphragmatic hernia 115 

21. Temperature chart in inanition fever 120 

22. Human milk: A. colostrum period; B, later period 128 

2:>. Apparatus for examination of human milk 132 

24. A. Babcock tubes; B, Lewi's modification for human milk . . . 133 

25. Freeman pasteuriser 152 

26. Weight curve of nursing and artificial feeding compared . . . 165 

27. Weight curve showing effect of bad nursing and good feeding . 173 

28. Chart showing effect of pregnancy on weight of nursing infant . 175 

29. Weight curve of infant properly weaned 176 

30. Weight curve of artificially fed infant, showing effect of beginning 

with too high percentages 192 

31. Weight chart showing the effect of intelligent care 201 

32. Case of marasmus 230 

33. Case of scurvy . 236 

34. Normal bone 246 

35. Rachitic bone 247 

36. Rachitic skull, inside view 249 

37. Rachitic head 250 

38. Rachitic skull, external view 250 

39. Rachitic thorax in outline 251 

40. Rachitic spine 252 

41. Multiple fractures in rickets 253 

42. Rachitic bow-legs 253 

43. Rachitic knock-knees 254 

44. Epithelial desquamation of the tongue . . . . . . . 265 

45. Thrush 276 

46. Gangrenous stomatitis 281 

47. Adenoid vegetations 289 

48. Temperature chart, streptococcus angina following measles . . . 297 

49. Gastric peristalsis in pyloric stenosis 315 

50. Malformations of the rectum 341 

51. Chart showing mortality from diarrhoeal diseases in New York . . 344 

52. Chart showing deaths under one year per 1,000 of population under 

one year, New York City, summer months 345 

53. Temperature chart of acute intestinal intoxication with fatal relapse 354 

54. Acute catarrhal ileo-colitis, superficial type 368 

55. Acute catarrhal ileo-colitis, severe form 369 

56. Follicular ulceration of the colon, early stage 370 

57. Follicular ulceration of the colon, later stage 371 

58. Membranous colitis 373 

59. Weight curve showing loss from ileo-colitis 375 

('>(). Temperature chart in ileo-colitis 377 

61. Temperature chart in membranous colitis 379 

62. Temperature chart in membranous colitis 380 



LIST OF ILLUSTRATIONS. xvii 

FIGURE PAGE 

63. Chronic catarrhal inflammation of the ileum 384 

64. Chronic intestinal indigestion 396 

65. Ileo-caecal intussusception 408 

60. Mechanism of intussusception 409 

67. Ascaris lumbricoides 422 

68. Oxyuris vermicularis 424 

69. Prolapsus ani 427 

70. An air vesicle in broncho-pneumonia 489 

71. An air vesicle in lobar pneumonia 490 

72. Broncho-pneumonia with thickened bronchus 494 

73. Broncho-pneumonia with emphysema 497 

74. Broncho-pneumonia, diffuse purulent infiltration 498 

75. Persistent broncho-pneumonia 499 

76. Temperature chart in mild uncomplicated broncho-pneumonia . . 505 

77. Temperature chart, prolonged broncho-pneumonia 505 

78. Temperature chart, relapsing broncho-pneumonia 506 

79. Temperature chart, rapidly fatal broncho-pneumonia .... 506 
80-83. Physical signs in broncho-pneumonia 508 

84. Temperature chart, persistent broncho-pneumonia 510 

85. Temperature chart, broncho-pneumonia following pertussis . . .511 

86. Temperature chart, typical lobar pneumonia 526 

87. Temperature chart, remittent type, lobar pneumonia .... 526 

88. Temperature chart, lobar pneumonia, subnormal temperature after crisis 526 

89. Temperature chart, abortive pneumonia 527 

90-92. Physical signs, lobar pneumonia 530 

93. Section of lung, showing distribution of fluid in chest .... 555 

94. Temperature chart, empyema following pneumonia .... 556 

95. Temperature chart, empyema following pneumonia .... 557 

96. Deformity after old empyema 562 

97. Apparatus for inducing pulmonary expansion after empyema . 563 

98. Congenital cardiac disease 569 

99. Clubbing of fingers in congenital cardiac disease 572 

100-101. Pericarditis with effusion — X-ray 579 

102. Congenital malformations of the kidneys and ureters .... 608 

103. Sarcoma of the kidney 623 

104. Tetany 657 

105. Spasmodic torticollis 678 

106. Meningocele 694 

107. Encephalocele 694 

108. Hydr encephalocele 694 

109. Meningocele 695 

110. Frontal meningocele 695 

111. Naso-frontal meningocele 695 

112. Incidence of cerebro-spinal meningitis 701 

113. Posture in cerebro-spinal meningitis 705 

114. Temperature chart, cerebro-spinal meningitis, recovery .... 708 

115. Temperature chart, cerebro-spinal meningitis, treated by serum . .714 

116. Temperature chart, cerebro-spinal meningitis, with late injection of 

serum 714 

117. Temperature chart, cerebro-spinal meningitis, termination by crisis 715 

118. Seasonal occurrence of tuberculous meningitis 722 

119. Tracing of respiration in tuberculous meningitis 724 



xviil LIST OF ILLUSTRATIONS. 

I'liil UK PAGH 

120. Temperature chart in tuberculous meningitis 725 

121. Chronic basilar meningitis 728 

122. Chronic basilar meningitis 729 

!•_':>. Brain in external hydrocephalus 741 

124. Vertical transverse section of a brain in congenital hydrocephalus . 743 

125. Head in chronic hydrocephalus 744 

126. Brain showing atrophy 748 

127. Convulsions in spastic paraplegia 740 

128. Spastic paraplegia 750 

1 •_'!>. Recenl meningeal haemorrhage 752 

130. Infantile hemiplegia showing contractures 754 

131-1 86. Various types of mental defect 757 

137. Brain in idiocy 758 

138. Chondro-dystrophy, radiograph of skull ....... 762 

139. Chondro-dystrophy j long bones 763 

140. Chondro-dystrophy, infantile figure 763 

141. Chondro-dystrophy, trident hand 764 

142. Chondro-dystrophy, adult figure 764 

143. A typical cretin 766 

144-145. Cretins, showing effect of thyroid treatment 767 

140-147. Cretins, showing effect of thyroid treatment 768 

14S. Spina bifida, meningocele (partially diagrammatic) .... 773 

140. Spina bifida, meningocele 774 

150. Spina bifida, meningo-myelocele (partially diagrammatic) . . . 774 

151. Spina bifida, syringo-myelocele 775 

152. Spina bifida, sacral 776 

153. Epidemic of poliomyelitis 784 

154. Infantile spinal paralysis of lower extremity 789 

155. Infantile spinal paralysis of shoulder . . 790 

156. Muscular pseudo-hypertrophy 798 

157. Alcoholic neuritis 802 

158. Diphtheritic paralysis 803 

159. Facial paralysis 808 

160. Enlarged thymus 833 

161. Acute suppurative adenitis, cervical 837 

162. Acute suppurative adenitis, inguinal 838 

163. Chain of tuberculous lymph nodes 843 

104. Cicatrices following tuberculous adenitis 845 

165. Section of the spine in Pott's disease 855 

166. Hip- joint disease 861 

107. Tuberculous dactylitis 866 

108. Hereditary syphilis 868 

169. Syphilitic periostitis of the fibula, radiograph 869 

170. Syphilitic osteo-periostitis of the tibia 870 

171. Syphilitic osteo-periostitis of the tibia, radiograph 871 

172. Syphilitic bone disease in a boy four years old 872 

173-174. Syphilitic dactylitis 874 

175-176. Syphilitic dactylitis, radiograph 874 

177. Congenital ichthyosis 876 

17H. Temperature chart, acute otitis, following influenza .... 896 

179. Temperature chart, acute otitis, early paracentesis 897 

180. Temperature charts in scarlet fever, mild cases 910 



LIST OF ILLUSTRATIONS. xix 

FIGURE PAGH 

181. Temperature chart in scarlet fever, typical curve 911 

182. Temperature chart in severe uncomplicated scarlet fever . . . 912 

183. Temperature chart in fatal septic scarlet fever 913 

]S4. Temperature chart in scarlet fever with late otitis .... 917 

185. Temperature chart in scarlet fever with late nephritis .... 918 

180-187. Temperature charts in measles, typical curve 934 

188. Temperature chart in measles, occasional course 934 

189. Temperature chart in measles, prolonged course 935 

190-191. Temperature charts in measles complicated by pneumonia . . 935 

192. Table showing protective power of vaccination 949 

193-197. Vaccination vesicles 952 

198. Generalised vaccinia 953 

199. O'Dwyer's intubation set 1003 

200. Temperature chart in typhoid fever, short course 1012 

201. Temperature chart in typhoid fever, with relapse 1012 

202. Tuberculous broncho-pneumonia, diffuse consolidation .... 1025 

203. Cavity from tuberculous broncho-pneumonia 1025 

204. Pulmonary tuberculosis, extensive caseation 1026 

205. Miliary tuberculosis of the lungs 1033 

20G. Temperature chart of tuberculosis following measles .... 1037 

207. Temperature chart of tuberculous broncho-pneumonia, general tuber- 

culosis 1038 

208. Temperature chart of tuberculous broncho-pneumonia with softening . 1039 

209. Tuberculous bronchial glands 1047 

210. Early eruption of hereditary syphilis, legs 1059 

211. Early eruption of hereditary syphilis, face 1060 

212. Syphilitic scaling of the sole 1060 

213. A later form of eruption in hereditary syphilis 1061 

214. Syphilitic notched teeth 1062 

215. Syphilitic teeth, variously deformed 1063 

216. Temperature chart of severe influenza in an infant .... 1071 

217. Temperature chart of acute broncho-pneumonia complicating influenza 1072 

218. Temperature chart, influenza, bronchitis, otitis 1074 

219. Temperature chart, quotidian intermittent fever 1077 

220. Temperature chart, tertian intermittent fever 1078 

221. Temperature chart in malaria, irregular type 1079 



THE DISEASES OF INFANCY AND CHILDHOOD. 

PART I. 



CHAPTER I. 

HYGIENE AND GENERAL CARE OF INFANTS AND YOUNG 

CHILDREN. 

The physical development of the child is essentially the product of 
the three factors — inheritance, surroundings, and food. The first of these 
it is beyond the physician's power to alter ; the second is largely and the 
third almost entirely within his control, at least in the more intelligent 
classes of society. These two subjects, infant hygiene and infant feeding, 
are the most important departments of paediatrics. 

The Care of the Newly-Born Child. — After the ligature of the cord the 
child should be wrapped in a thick blanket and placed in a warm room. 
In hospital practice the eyes should be cleansed with absorbent cotton 
and water which has been boiled, and then two or three drops of a two- 
per-cent solution of nitrate of silver, after C rede's method, instilled into 
each eye by means of a glass rod or eye-dropper. In private practice a 
ten-per-cent solution of argyrol may be substituted, unless the mother 
has had a purulent vaginal discharge, in which case the silver solution 
should always be used. The bath should now be given in a warm room ; 
the body being first oiled thoroughly in order to remove the vernix caseosa 
and then washed in water at a temperature of 100° F. The mouth should 
be cleansed with sterile water and a soft cloth, and no violence em- 
ployed. The cord may be covered with sterilised talcum or bismuth 
powder, and wrapped in sterile gauze or surgeon's lint. The abdomen 
/should now be enveloped in a flannel band, eight or ten inches wide, and 
pinned rather snugly. Before dressing is completed, the child should 
be submitted to a thorough examination for injuries received during 
delivery, congenital deformities, also as to the condition of the respira- 
tion, circulation, etc. 

After dressing, the child should be placed in his crib and covered 

with blankets, and if the feet are cold, or the fingers and lips a little blue, 

he should be surrounded by hot-water bottles covered with flannels, and 

placed near, but not in contact with, the body. The crib should be placed 

2 1 



2 HYGIENE AND GENERAL CARE. 

in a quiet, darkened room. The young infant should not occupy the 
same bod as the mother, unless lie greatly needs the warmth of her body, 
other means of artificial heat not being at hand. 

The cord should be kept dry and disturbed as little as possible until 
it falls off. Under ordinary circumstances the cord separates from the 
fourth to the seventh day, the average being the fifth day. The stump 
should then be covered with the sterilised talcum or bismuth powder, 
and a pad of sterile gauze about one-fourth of an inch thick and two 
inches square applied and secured in position by means of the abdominal 
band. The purpose of this is to prevent umbilical hernia. The pad 
should be continued for the first month. The use of stronger antiseptic 
dressings than those recommended is somewhat objectionable, since it 
preserves the cord too long and delays separation. The full bath should 
not be given until the cord has separated. 

The physician should always see to it that the infant cries enough to 
keep the lungs properly expanded. 

The question of food for the newly-born infant is considered in the 
chapter upon infant feeding. 

Bathing. — For the first few months the bath should be given at 98° 
F. The room should be warm, preferably there should be an open fire. 
The bath should be short and the body dried quickly, without too vigor- 
ous rubbing. The addition of salt to the bath is an advantage where the 
skin is unusually delicate or excoriations are present. One large handful 
should be used to a gallon of water. By the sixth month the temperature 
of the bath for healthy infants may be lowered to 95° F., and by the end 
of the first year to 90° F. Older children who are healthy should be 
sponged or douched for a moment at the close of the tepid bath with 
water at 65° or 70° F. During childhood the warm bath is preferably 
given at night. In the morning a cold sponge bath is desirable. This 
should be given in a warm room and while the child stands in a tub 
partly filled with warm water. This cold sponge should last but half a 
minute, and be followed by a brisk rubbing of the entire body. 

In some young infants and even older children there is no proper 
reaction after the bath, even when given at the temperatures mentioned ; 
children being pale, slightly blue about the lips and under the eyes. All 
tub bathing, and especially all cold bathing, should then be stopped, since 
a continuance can only be a drain upon the child's .vitality. 

Clothing. — The clothing of infants should be light, warm, non-irri- 
tating to the skin, and loose enough to allow free motion of the ex- 
tremities; nor should bands be pinned so tightly about the trunk as to 
embarrass the movements either of the chest or of the abdomen. The 
chest should be covered with a woollen shirt, high in the neck and with 
long sleeves. All petticoats should be supported from the shoulders and 
not from waistbands. Canton flannel and stockinet are both superior as 



CARE OF THE EYES, MOUTH, AND TEETH. 3 

absorbents to the more commonly used linen diapers. Stockinet has the 
advantage of being very soft and pliable. Care should be taken that in 
infants the feet be kept warm. If the circulation is very poor, a bag of 
hot water should always be in the crib. Cold feet are responsible for 
many attacks of colic. 

The abdominal band is usually worn during infancy. It cannot be 
considered in any sense a necessity after the first few months, excepting 
in cases of very thin infants whose supply of fat in the abdominal walls 
is an insufficient protection to the viscera. For the first few weeks a band 
of plain flannel is to be preferred; later, a knitted band with shoulder- 
straps. The fashion of low neck and short sleeves for infants and very 
young children has fortunately passed away — let us hope, never to 
return. 

During the summer the outer clothing should be light and the under 
clothing of the thinnest flannel or gauze. The changes in the tempera- 
ture of morning and evening may be met by extra wraps. The custom of 
allowing young children to go with legs bare has many enthusiastic advo- 
cates; while it may not be objectionable during the heat of summer, its 
advantages at any season are very questionable in a changeable climate 
like that of New York or the Atlantic coast. Many delicate children are 
certainly injured by .such ill-advised attempts at hardening. 

The night clothing of infants should be similar to that worn during 
the day, but should be loose, the material being of the lightest flannel. 
The night clothing for older children should consist of a thin woollen 
shirt and a union suit with waist and trousers, and in some cases with 
feet, if there is a tendency to get outside the coverings. The common 
mistake is to overload all children, but especially infants, with covering 
at night. This is an explanation of much of the restless sleep which is 
seen particularly in delicate children. 

Care of the Eyes. — During the first few days at the daily bath the 
eyes should be cleansed with a saturated solution of boric acid. They 
should be carefully protected from too strong light during early infancy. 
It is desirable that a child should always sleep in a darkened room. 

Care of the Mouth and Teeth. — The mouth of the newly-born infant 
should be gently cleansed at each morning bath with boiled water and 
a soft cloth. On the first appearance of thrush the mouth should be 
washed after every feeding with a solution of bicarbonate of soda or 
boric acid (ten grains to the ounce). It should be applied with a swab 
made by twisting a bit of cotton upon a wooden toothpick, and not by 
the nurse's finger. Harm is often done by the use of too much zeal in 
cleansing the mouth of a young infant. 

The primary teeth as well as those of the permanent set should receive 
daily attention. Too often they are neglected altogether. Dirty teeth 
are likely sooner or later to become carious; and carious teeth, besides 



4 HYCIENE AND GENERAL CARE. 

being a cause of bad breath and neuralgia, are a constant menace to the 
health of the child, since they may harbour infectious germs of all varie- 
ties. Such teeth should either be filled or removed. 

Care of the Skin. — The skin of a young infant is exceedingly deli- 
cate, and excoriations, intertrigo, and eczema are of very common occur- 
rence. These conditions are much easier of prevention than of cure. 
The first essential in the care of the skin is cleanliness, and this must 
be secured without the use of strong soaps or too much rubbing. Nap- 
kins must be removed as soon as soiled or wet. Some bland absorbent 
powder, like starch, talcum, or the stearate of zinc, should be used in all 
the folds of the skin, in the neck, in the axillae, groins, and about the 
genitals, and in the folds of the thighs, particularly in very fat infants. 
If plain water produces an undue amount of irritation, the salt or bran 
bath should be employed. 

Care of the Genital Organs. — The female genitals need but little 
attention in young children, excepting as to cleanliness. This is more 
often neglected in older children than in infants. 

In males the prepuce should receive attention during the first few 
weeks of life. If the foreskin is long and the preputial orifice small, 
circumcision should be done. If it is not long, but is only adherent, 
these adhesions should be broken up, the parts thoroughly cleansed and 
the foreskin retracted daily until there is no disposition to a recurrence 
of the adhesions. These operations will be discussed more at length in 
a subsequent chapter. The only thing to be emphasised in the present 
connection is that the prepuce should receive proper attention in early 
infancy, since this can now be done with less pain and discomfort to the 
child, and at the same time better results are obtained. If this matter 
is neglected during infancy, it is apt to be overlooked until harm has 
been produced by local or reflex irritation which phimosis or adherent 
prepuce may have excited. 

Vaccination. — This, although considered elsewhere, should be men- 
tioned in this connection as among the things requiring the physician's 
attention during the first months of life. 

Training to Proper Control of Rectum and Bladder. — It is surprising 
to see what can be accomplished by intelligent efforts at training in 
these particulars. An infant can often be trained at three months to 
have its movements from the bowels when placed upon a small cham- 
ber. This not only saves a great amount of washing of napkins, but 
there is soon formed a habit of having the bowels move at a regular time 
or times each day. The infant must be put upon the chamber soon after 
his feeding. The importance of training young children to regular habits 
regarding evacuations from the bowels can hardly be overestimated. It 
should be impressed upon every mother and nurse by the physician, and 
especially the necessity of beginning training during infancy. Much of 



SLEEP. 5 

course will depend upon the food and the digestion; but habit is a very 
large factor in the case. 

The training of the bladder is not quite so important, but the proper 
education of this organ adds much to the comfort of the child and the ease 
with which it is cared for. Before the end of the first year many intelli- 
gent children can be trained to indicate a desire to empty the bladder. 
Many mothers and nurses succeed in training children so well that by 
the tenth or eleventh month napkins are dispensed with during the day. 
On the other hand, it is very common to see children of two and even two 
and a half years still wearing napkins because of the lack of proper 
training. Before it has reached the age of three years a healthy child 
will usually go from 10 p.m. until morning without emptying the bladder. 
The annoyance and discomfort from the neglect of early training in this 
particular are very great. Night feeding is responsible for much of the 
difficulty experienced in training children to hold the water during the 
night. 

General Hygiene of the Nervous System. — Great injury is done to 
the nervous system of children by the influences with which they are 
surrounded during infancy, especially during the first year. The brain 
grows more during the first two years than in all the rest of life. Nor- 
mal healthy development of the nervous centres demands quiet, rest, 
peaceful surroundings, and freedom from everything which causes ex- 
citement or undue stimulation. 

The steadily increasing frequency of functional nervous diseases 
among young children is one of the most powerful arguments for greater 
attention by physicians to the subject of the hygiene of the nervous sys- 
tem during infancy. Most parents err through ignorance. Playing with 
} r oung children, stimulating to laughter and exciting them by sights, 
sounds, or movements until they shriek with apparent delight, may be a 
source of amusement to fond parents and admiring spectators, but it is 
almost invariably an injury to the child. This is especially harmful when 
done in the evening. It is the plain duty of the physician to enlighten 
parents upon this point, and insist that the infant shall be kept quiet, 
and that all such playing and romping as has been referred to shall, 
during the first year at least, be absolutely prohibited. 

Sleep. — The sleep of the newly-born infant is profound for the first 
two or three days and under normal conditions almost continuous. In 
the case of prolonged or tedious labour, or where from any cause undue 
compression has been exerted upon the head, it may approach the con- 
dition of semi-coma for twenty-four or forty-eight hours. This may be 
so deep as to excite apprehensions of serious brain lesions. If, however, 
there are associated with it no convulsions and no rigidity, this early 
stupor usually passes away on the second or third day. 

The sleep of early infancy is quiet and peaceful, but not very deep 



6 HYGIENE AND GENERAL CARE. 

after the first month. After the third year the heavy sleep of childhood 
is commonly seen. A healthy infant during the first few weeks sleeps 
from twenty to twenty-two hours out of the twenty-four, waking only 
from hunger, discomfort, or pain. During the first six months a 
healthy infant will usually sleep from sixteen to eighteen hours a day, 
the waking periods heing only from half an hour to two hours long. At 
the age of one year most infants sleep from fourteen to fifteen hours, 
viz., from eleven to twelve hours at night, and two or three hours during 
the day, usually in two naps. When two years old usually thirteen to 
fourteen hours' sleep is taken; eleven or twelve hours at night and one 
or two hours during the day, generally in a single nap. At the age of 
four years children require from eleven to twelve hours' sleep. It is 
always desirable, and in most cases with regularity it is possible, to keep 
up the daily nap until children are four years old. From six to ten 
years the amount of sleep required is ten or eleven hours, and from ten 
to sixteen years nine hours should be the minimum. 

Training in proper habits of sleep should be begun at birth. From 
the outset an infant should be accustomed to being put into his crib while 
awake and to go to sleep of his own accord. Rocking and all other habits 
of this sort are useless and may even be harmful. An infant should not 
be allowed to sleep on the breast of the nurse, nor with the nipple of the 
bottle in his mouth. Other devices for putting infants to sleep, such as 
allowing the child to suck a rubber nipple or anything else, are positively 
injurious. If such means of inducing sleep are resorted to the infant 
soon acquires the habit of not sleeping without them. I have known of 
one instance where the habit of rocking during sleep was continued until 
the child was two years old; the moment the rocking was stopped the 
infant would wake, and in consequence this practice was continued by 
the devoted but misguided parents. A quiet, darkened room, a warm 
and comfortable bed, an appetite satisfied, and dry napkins are all that 
are needed to induce sleep in a healthy child. 

The periods of sleep in young infants are usually from two to three 
hours long, with the exception of once or twice in the twenty-four hours, 
when a long sleep of five or six hours occurs. The purpose of training 
is to have the child take this long sleep at night. The habit of regular 
sleep is best established by wakening the infant regularly every two or 
two and a half hours during the day for feeding, and allowing it to sleep 
as long as possible during the night. This training goes hand-in-hand 
with regular habits of feeding. Such habits are easily formed if the 
plan be systematically followed from the outset. 

By the fifth month all feeding between 10 p.m. and 7 a.m. should be 
discontinued. If this is done most infants can be trained by this time 
to sleep all night. If the room is lighted, and the child taken from the 
crib or rocked or fed as soon as he wakens at night, there is no such thing 



EXERCISE. 7 

as the formation of good habits of sleep. Kegularity in sleep and feeding 
not only make the care of young infants very much easier, but they are 
of a good deal of importance for the health of the child. 

The causes of disturbed or irregular sleep in young infants are mainly 
two — hunger and indigestion. In nursing infants it is usually the for- 
mer; in those artificially fed usually the latter. Sleeplessness from hun- 
ger is often seen in children who are nursed thirty or forty minutes and 
then fall asleep, but wake in fifteen or twenty minutes crying and fretful. 
After being quieted they may fall asleep again for half an hour, but 
wake at short intervals. The peaceful sleep of two or three hours which 
should follow a proper feeding is never seen. With this restlessness, in 
indigestion other signs are usually present, stationary weight, etc. The 
disturbed sleep due to overfeeding shows itself by much the same symp- 
toms, excepting that the first sleep after the meal is usually longer. 

Exercise. — This is no less important in infancy than in later child- 
hood. An infant gets his exercise in the lusty cry which follows the cool 
sponge of the bath, in kicking his legs about, waving his arms, etc. By 
these means pulmonary expansion and muscular development are in- 
creased and the general nutrition promoted. An infant's clothing should 
be such as not to interfere with his exercise. Confinement of the legs 
should not be permitted. In hospital practice I have often had a chance 
to observe the bad results which follow when very young infants are 
allowed to lie in the cribs nearly all the time. Little by little the vital 
processes flag, the cry becomes feeble, the weight is first stationary, then 
there is a steady loss. The appetite fails so that food is at first taken 
without relish, then at times altogether refused; later, vomiting ensues 
and other symptoms of indigestion. This, in many cases, is the begin- 
ning of a steady downward course which goes on until a condition of 
hopeless marasmus is reached. Such infants must be taken up every few 
hours and carried about the wards; the position should be frequently 
changed, and general friction of the entire body employed at least twice 
a day. Every means must be made use of to stimulate the vital activity. 
The value of systematic attention to these matters cannot be overesti- 
mated in hospitals for infants. Infants who are old enough to creep or 
stand usually take sufficient exercise unless they are restrained. At this 
age they should be allowed to do what they are eager to do. Every 
facility should be afforded for using their muscles. Exercise may be 
encouraged by placing upon the floor in a warm room a mattress or a 
thick " comfortable," and allowing the infant to roll and tumble upon it 
at will. A large bed may answer the same purpose. 

In older children every form of out-of-door exercise should be encour- 
aged — ball, tennis, and all running games, horseback riding, the bicycle, 
tricycle, swimming, coasting, and skating. Up to the eleventh year no 
difference need be made in the exercise of the two sexes. Companion- 



S HYGIENE AM) GENERAL CARE. 

ship is ;i necessity. Children broughl up alone are al a great disadvantage 
in tliis respect, and are no1 likely to gel as much exercise as they require. 
The amount of exercise allowed delicate children should be regulated 
with some degree of care. It may be carried to the point of moderate 
muscular fatigue, bul never to muscular exhaustion. The latter is par- 
ticularly likely to be the case in competitive games. 

Exercise should have reference to the symmetrical developmen of the 
whole body. In prescribing it the specific needs of the individual child 
should be considered. By carefully regulated exercises very much may 
be done to check such deformities as round shoulders and slight lateral 
curvature of the spine, and also to develop narrow chests and feeble 
thoracic muscles. For purposes like these, gymnastics are exceedingly 
valuable to supplement out-of-door exercise, but they can never take 
their place. 

There are two important points with reference to exercise indoors. 
First, the playroom should be cool — about 60° F. Secondly, during all 
active exercise the clothing should be loose and light, so as to allow the 
freest possible motion of the body. 

Airing. — In summer there can be no possible objection to a young 
infant being allowed out of doors at the end of the first week. He should 
be kept in the open air as much as possible during the day. In the fall 
and spring this should not be permitted until the child is at least a 
month old, and then only when the out-of-door temperature is above 60° 
F. During his outing the head should be protected from the wind and 
the eyes from the sun. The duration of the outing at first should be 
only fifteen or tw r enty minutes, the time being gradually lengthened to 
two or three hours. The child should be gradually accustomed to changes 
of temperature in the room by opening wide the windows for a few min- 
utes each day even before it is taken out of doors, the child being 
dressed meanwhile as for an outing. In the case of children born late 
in the fall or in the winter this means of giving fresh air may be ad- 
vantageously begun at one month and followed throughout the first win- 
ter. It is only necessary in all such cases that the changes be made very 
gradually both as to the length of the airing and as to the temperature. 
The great advantage of this plan over that more commonly followed 
of keeping young infants closely housed for the first six months in case 
they are born in the fall or early winter, I can positively affirm from 
quite a wide observation of both methods. It is a matter of very serious 
importance that every infant be furnished an abundance of pure fresh 
air in winter as well as in summer. When the plan above outlined is 
carefully and judiciously followed, the tendency to catarrhal affections 
instead of being increased is thereby greatly lessened. 

When four or five months old, there is no reason why a healthy child 
should not go out of doors on pleasant days if the temperature is not 



NURSERY. 9 

below 20° F. While there is a prejudice on the part of many mothers 
and some physicians against a child's sleeping out of doors in cold 
weather, it is a practice which I have always urged upon mothers, and 
have never seen followed by any but the most beneficial results. The 
days of all others when infants and very young children should not be 
out of doors are when there are high winds, especially those from the 
northeast, an atmosphere of melting snow, and during severe storms. 
Delicate infants must of course be more carefully guarded during the 
cold season. "With most of these the plan of house-airing is all that 
should be attempted. 

Nursery. — This should be the sunniest and best-ventilated room in 
the house. It is the physician's duty to see that proper attention is paid 
to the hygiene of the room in which the child spends at least four-fifths 
of his time during the first year, and two-thirds of his time during the 
first two or three years of life. Sunlight is absolutely indispensable. 
Sunny rooms always contain less organic matter and less humidity, and 
hence a room upon the north side of the house should always be avoided, 
preferably one in the second story should be chosen. Nothing which can 
in any way contaminate the air of the room should be allowed. There 
should be no drying of clothes or of napkins, and no plumbing. No 
food should be allowed to stand about the room. The gas should not be 
allowed to burn at night; a small wax night-light furnishes all that is 
needed in the nursery. If possible the heat should be from an open fire ; 
the next best thing is the Franklin heater. Nothing in the room is 
worse than steam heat from a radiator unless it be a gas stove, which 
under no circumstances should be allowed, excepting possibly for a few 
minutes each morning during the bath. 

The temperature of the room during the day should not be over 
70° F. It is important that every nursery should have a thermometer, 
and that this and not the sensations of the nurse should be the guide. 
It is almost invariably true that the nursery is overheated. Often no 
other explanation can be found for chronic indigestion and falling weight 
excepting a nursery whose habitual temperature ranges from 75° to 80° 
F. At night for the first few weeks the temperature should not be 
allowed to fall below 65° F. After two months the night temperature 
may fall to 60° or even 50° F. 

Free ventilation without draughts is an absolute necessity. This is 
best accomplished by ventilators in the windows, of which there are 
many excellent devices sold in the shops. While the child is absent from 
the room the windows should be widely opened and free airing of the 
nursery accomplished. The room should always be thoroughly aired at 
night before the child is put to bed. The window may be kept open 
after the third month. After the first year the window may be open, 
unless the outside temperature is as iow as 20° F. If the window is 



10 HYGIENE AM) GENERAL CARE. 

open the door <>f the aursery should be dosed, thai currents of air may 
be avoided. The ventilation by means of an open fire is the most 
efficient 

The furniture o( the nursery should be as simple as possible, heavy 
hangings should be positively forbidden, and upholstered furniture used 
only to a small extent. Floors covered by large rugs are much more 
cleanly than ear pets, and hence are to be preferred. 

The child, whenever it is possible, should have a separate bed; and 
so should the newly-born infant, in order to prevent the danger of over- 
lying by the mother, which among the lower classes is a frequent cause 
o( death, and also to avoid the danger of too frequent night nursing, 
which is injurious alike to mother and child. Separate beds for older 
children will prevent the spread of many forms of infection. The cradle 
for infants should be one which does not rock, in order that this unnec- 
essary and vicious practice may not be carried on. The mattress should 
be of hair and quite firm. The pillow should be small; in the summer, 
hair pillows are an advantage but not a necessity. The position of the 
child during sleep should be changed from time to time from one side 
to the other and then to the back. Attention to all these details should 
not be beneath the physician's notice, since the violation of these plain 
rules of hygiene is at the bottom of many of the milder disorders and 
even of some of the more serious diseases seen in infancy. 

The Nurse. — The nurse of a young child should be healthy, young 
or in middle life, free from tuberculous or syphilitic taint, from catar- 
rhal affections of the nose and throat, and not of a nervous or excitable 
temperament. She should be neat in habit, of quiet disposition, and, 
most of all, she should be a person of intelligence. 

The Amount of Air Space required by Infants. — The nursery should 
always be as large a room as possible. One of the reasons why young 
infants do so badly in institutions is because of overcrowding. In a 
well-ventilated ward there should be allowed to each infant at least 1,000 
cubic feet. Children over two years old are not so sensitive to their 
surroundings, and may thrive in wards where only 700 or 800 cubic feet 
are allowed to each child. 

THE CARE OF PREMATURE AND DELICATE INFANTS. 

Infants born before term, and some exceedingly delicate ones who 
are born at full term, require very special and particular care. The 
vitality is so feeble in these children that if they are handled in the 
ordinary way they survive at most but a few weeks. The symptom which 
indicates that such special care is necessary is most of all the weight of 
the child. Either congenital feebleness or prematurity may be assumed 
in most of the children weighing less than four pounds ; also if the length 



PREMATURE AND DELICATE INFANTS. 11 

of the body is less than nineteen inches. In these children all the organs 
are likely to be imperfectly developed and they are not ready for their 
work. Especially is this true of the lungs and of the organs of digestion. 

The clinical picture presented by these cases is quite characteristic. 
The body is limp ; the skin very soft and delicate and almost transparent ; 
the cry, a low feeble whine not unlike the mew of a kitten; the respira- 
tory movements, extremely irregular, sometimes scarcely perceptible for 
several seconds; the movements of the extremities infrequent and never 
vigorous. The general appearance is one of torpor. The muscles of the 
mouth and cheek and tongue may lack the requisite force for sucking, 
so that this is practically impossible, and even deglutition is slow, dif- 
ficult, and prolonged. It is difficult to maintain the normal body tem- 
perature; unless closely watched this may fall far below the normal, 
and may rise quite as much above it with the use of too much artificial 
heat. I once saw a fluctuation of 13° F. occur in a few hours from such 
causes. All the symptoms mentioned vary much according to the degree 
of prematurity. 

In the management of these cases there are three problems to be 
solved: the first to maintain the animal heat, the second to nourish the 
infant, the third to prevent infection. Difficult as it always is to rear 
a premature infant, these difficulties are much increased in cases where 
proper means are not adopted immediately after birth. The loss which 
these children sustain during the first few days is in very many cases 
so great that subsequent measures, however well carried out, are futile. 
The heat-producing power is so feeble that the body temperature quickly 
falls below normal unless artificial heat is constantly used. The effect 
of cold upon these delicate infants is very serious, and not only growth 
but even life depends upon maintaining the body temperature steadily 
and uniformly. Their extreme susceptibility is something which it is 
difficult for one to appreciate who has not had experience in these cases. 

One of the simplest means of maintaining the temperature is to oil 
the skin and then roll the entire body, including extremities, in absorbent 
cotton or lamb's wool ; even the neck and cranium may be covered, leav- 
ing only the face exposed. The usual diaper may be replaced by a pad 
of gauze and absorbent cotton. The body is then wrapped in blankets, 
placed in a clothes-basket or bassinet with protected sides, and sur- 
rounded by bottles or bags containing hot water. A blanket or sheet 
should partially cover the top of the basket, forming a sort of hood to 
protect the eyes from light and the face and head from draughts. In 
using hot-water bags, some caution must be exercised or too much heat 
may be secured. I have seen the temperature of an infant raised six 
or seven degrees from this cause. The temperature of the child should 
at first be taken every few hours to make sure that a proper amount of 
external heat is supplied. 



12 HYGIENE AND GENERAL CARE. 

A more efficient moans of Furnishing artificial heat is by the electric 
pad. These small heaters are attached to an electric fixture like a drop- 
light. A convenient size is ten by fifteen inches. The pad, which can be 
obtained of any electric supply company, is placed beneath two or three 
thicknesses of blanket, upon which the infant lies in its basket. Since 
the pads occasionally get out of order they must be used with some cau- 
tion, as they have been known to burn the bedclothes and even the baby. 

With such means as those described it is possible to maintain the 
body temperature at normal even in a room kept at the ordinary tem- 
perature. It is preferable to have a warmer room; 75° or even 80° F. 
is desirable for feeble infants. Adequate ventilation, however, is indis- 
pensable. With intelligent care excellent results can, however, often be 
obtained with no other means for maintaining heat than the padded 
basket and hot-water bottles ; but the other accessories make the problem 
an easier one. 

Premature infants should be fed without being removed from the 
basket, until they are strong enough to take the breast. The posi- 
tion should be frequently changed and some freedom of movement of the 
limbs permitted, but the infants should be handled as little as possible. 
The body should be oiled and fresh cotton applied every other day. The 
rectal temperature at first should be taken several times a day in order 
to be sure that sufficient artificial heat is being supplied, but not too 
much. The latter condition is one that often obtains. So long as the 
rectal temperature varies only between 98° and 100° F. one should be 
satisfied. 

Incubators. — Personally, I have not found the usual small incubator 
a very satisfactory means of caring for the premature infant. The dif- 
ficulties in successful operation are many and the dangers consequent 
upon the mode of ventilation are considerable. Except by persons 
experienced, their use is not to be advised. In hospitals with spe- 
cially trained nurses they may give excellent results, but in the aver- 
age home the simpler measures above described are much safer and 
quite efficient. 

Every institution receiving and caring for premature infants should 
have a specially equipped room for that purpose. It should be of suffi- 
cient size to accommodate several patients. We have had such a room con- 
structed in the Babies' Hospital which seems to fulfill all the requirements. 
The room has a floor space of thirteen by sixteen feet with ceiling eleven 
feet high. This is arranged for five infants, which gives each child 450 
cubic feet of air. The cribs are separated by glass plates, which project 
three feet from the side wall and are four feet in height, forming for 
each infant a sort of alcove. The purpose of this is to diminish the 
chances of bed-to-bed infection. The room has double partition walls 
and double windows. The temperature is controlled by a thermostat 



PREMATURE AND DELICATE INFANTS. 



13 



regulator and is maintained at about 90° F. The room is provided 
with a special ventilating apparatus by means of which the entire air 
of the room can be changed in a few minutes. This is done several 
times a day. Such a room possesses all the advantages of the small in- 
cubator without any of its drawbacks. The infants are clothed in a 
single loose garment of absorbent cotton and cheese-cloth and lightly 
covered. In this room the normal body temperature is easily maintained. 
For wet-nursing, bathing, and changing of napkins, the children are 
removed to an anteroom which is kept at a temperature of about 75° F. 
When the bottle is given they are fed in their cribs. After reaching the 
weight of five and a half or six pounds they are removed to the anteroom 
for a few days, after which they are placed in the ward or sent home. 

Feeding. — The feeding of the premature infant is not less important 
than the maintenance of heat and proper ventilation. Infants at eight 
months and those weighing five pounds or thereabouts 
can usually be made to take the breast after the first few 
days. Few below this age or weight will do so. Some 
will suck from a bottle, but the majority must be fed 
by other means. A medicine dropper may be used, or 
the Breck feeder * ( Fig. 1 ) ; the smallest and feeblest, 
however, must be fed by gavage, using a funnel and 
small rubber catheter. The food should be slowly given ; 
if rapidly, some is liable to be regurgitated, and this may 
produce attacks of asphyxia or even an aspiration pneu- 
monia. The quantity of food and frequency of feeding 
will depend upon the size and age of the child. A seven 
months' baby weighing three and a half pounds should 
have, for the first twenty-four to thirty-six hours, only 
water, one to three teaspoonfuls every hour. Then regu- 
lar food, half an ounce every hour, gradually increased 
to an ounce every two hours at the end of two weeks, and 
an ounce and a half every two hours at the end of three 
weeks. 

Artificial feeding is seldom very successful with pre- 
mature infants. With some of the larger and more vig- 
orous, cow's milk modified according to the directions 
given in the chapters on Infant Feeding gives good re- 
sults. I once succeeded with a child of three pounds two ounces. For 
most of them under four and a half pounds, breast-milk is essential. 
If the child is born near term, the mother may be able to nurse it. Oc- 
casionally this may be done at eight months, but seldom earlier, so that 
the milk of some other woman must usually be depended upon. 



Fig. 1. — Breck's 
Feeding-Tube. 



1 Obtained at any of the Walker-Gordon laboratories. 



14 



HYGIENE AND GENERAL CARE. 



As the premature baby requires only from six to twelve ounces of 
breast-milk a day for the first few weeks, this may be secured from some 
other nursing woman ; a friend might be willing to furnish it or it could 
be purchased from any healthy woman who has an abundant supply. It 
is sufficient it' it is drawn fresh twice a day, the utmost precautions, of 
course, being taken to secure cleanliness. At first equal parts of breast- 
milk and a four- or five-per-cent solution of milk sugar may be given; 
the degree of dilution being gradually lessened until pure milk is taken. 
Twelve feedings a day are usually necessary, the amount at one feeding 
may be from two drachms to one ounce depending upon the size, age, 
and digestive powers of the infant. Since the breast-milk must always 
be diluted, at least at first, it is not important that the baby of the 
woman furnishing the milk should be of the same age as the foster 
infant. The milk of any woman whose baby is between one and eight 
months old will answer. I have successfully fed premature infants with 
breast-milk of women whose children were older than this. Another 
plan is to secure a wet-nurse and permit her to bring her own baby into 
the house. She pumps for the premature infant the required amount 
three or four times a day, and the rest of the time nurses her own child. 
In this way her flow of milk is maintained ; but if the breasts are pumped 
exclusively the supply rapidly diminishes. The secretion of the milk in 
the mother may be promoted by her suckling the wet-nurse's baby or 
some other vigorous infant. The above are temporary expedients and 
in most instances need not be continued more than two or three weeks, 
at the end of which time the mother may be able to nurse her own child. 

The results with premature babies will depend very much upon how 
soon after birth they receive proper care. Immediately after birth meas- 
ures should be taken to secure the best care and provide adequately for 
maintaining the body heat. If an incubator is to be used it should be 
in readiness, so that the child can be put into it as soon as it is breathing 
properly. The age and vigour of the infant are of the greatest impor- 
tance in estimating the chances of survival. The following table gives 
Tarnier's statistics, showing the percentage of premature infants saved 
during a period of five years without the incubator, and during the 
succeeding five years with the incubator; also the percentage saved at 
the Sloane Hospital (Xew York), as published by Voorhees: 



Age. 


Tarnier saved 
without incu- 
bators. 


Tarnier saved 
with incubators. 


Voorhees 
saved with 
incubators. 


Voorhees saved 

excluding cases 

dying a few 

hours after birth. 


Born at 6 months 

" " G| " 

It it 7 It 

" " 1\ 

" " 8 " 

" " 8§ " 


o.o% 

21.5% 
39.0% 
54.0% 
78.0% 
88.0% 


16.0% ' 

36.6% 

49.8% 

77.0% 

88.8% 

96.0% 


22.0% 
41.0% 
75.0% 
70.0% 


66.0% o 
71.0% 
89.0% 
91.0% 



WEIGHT. 15 

"Results will improve with the experience of the physician in the feed- 
ing and care of these very sensitive patients. Much is yet to be learned 
about them. 



CHAPTER II. 
GROWTH AND DEVELOPMENT OF THE BODY. 

Observations upon growth and development are of the utmost im- 
portance during infancy and childhood. Only by this means are very 
many diseases detected in their incipiency. Early recognition carries 
with it in most cases the possibility of checking such pathological proc- 
esses as, if allowed to go on, may affect the health not only in infancy 
but even throughout life. 

By familiarity with what is normal, detection of the abnormal soon 
becomes easy. Investigation in regard to these subjects should be made 
a part of the physical examination of every child. 

WEIGHT. 

The weight of the infant is the best means we have to measure his 
nutrition. It is as valuable a guide to the physician in infant feeding as 
is the temperature in a case of continued fever. Although the weight is 
not to be taken as the only guide to the child's condition, it is of such 
importance that we cannot afford to dispense with it during the first two 
years. It is a great advantage to keep up regular observations during 
childhood. 

Weekly weighings should be made for the first six months, bi-weekly 
for the rest of the first year, and monthly during the second year. 
Delicate children should be 

portion from the records of FlG 2 

the Nursery and Child's Hos- 
pital, the Sloane Maternity, and the New York Infant Asylum, and 
include only full-term children: 



K> GROWTH AND DEVELOPMENT. 

Average weight of 568 females 7.16 lbs. (3,260 grammes). 

590 males 7.55 " (3,400 " ). 

1,158 infants 7.35" (3,330 " ). 

Weight Curve during the First Few Weeks. — The accompanying 
chart represents the variations in weight for the first twenty days. These 
observations were made upon one hundred healthy, nursing infants, fifty 
males and fifty females, at the Nursery and Child's Hospital. The 
children were weighed daily during the period of observation. The 



X>^I3L,Y WEIGHT CH^RT. 
Name, Date of Birth, 189 


Gras. 


Lbs. 


1 


2 


3 


4 


5 


6 


7 


S 


9 


10 


11 


12 


13 


U 


15 


10 


17 


18 


19 


20 


4420 
1310 
4200 
4080 
3970 
3850 
3740 
3C30 
3510 
3400 
3290 
3180 
3060 
2940 
2830 
2720 
2610 
2490 
2380 


» 

tx 
ft 

8 

m 

6K 

6 

5^ 
5^ 
5M 








































































































































































































































































































































































































\^ 
















































\ 








































\ 








































\ 


V. 








































\ 


^ 


r*"' 











































































































































































































































Fig. 3. — Weight Curve of the First Twenty Days. 



average weight at birth was 7.1 pounds. The curve shows a very 
marked loss of weight on the first day and a slight loss on the second 
day, the lowest point being touched at the beginning of the third day; 
but from this time there was a steady gain. The average initial loss in 
these cases was ten ounces, being in each sex exactly eleven per cent of 
the body weight. In eight hundred and thirty-five cases, including those 
above mentioned, the average loss was nine and a half ounces. The loss 
of the first days is chiefly due to the discharge of the meconium and 
urine, but is in part from the excess of tissue waste over the nutriment 
derived from the breasts. After the third day, coincident with an abun- 
dant secretion of milk, there is a steady, daily increase in weight. If 
the milk is very scanty or is wanting altogether, the loss in weight 
continues. 



WEIGHT. 



17 



The birth-weight of nursing children who thrive normally is regained 
on the average on the tenth day. The most frequent deviation from the 
normal curve consists in a continued loss or stationary weight after the 
third day. This may be due to acute illness, such as bronchitis, diar- 
rhoea, pyaemia, or haemorrhage, but in the majority of cases there is a 
disturbance of nutrition from improper or insufficient food. 

The weight curve of infants who are artificially fed, even though 
they are strong and vigorous and the feeding properly done, rarely fol- 
lows for the first month the same lines as that of nursing infants. "We 
usually see an initial loss which is about the same as in nursing infants, 
then a period of nearly stationary weight lasting from one to two weeks. 

Excessive loss in weight during the first few days from any cause 
whatsoever, seriously handicaps an infant during the first weeks of its 
life. The great importance of this has not been sufficiently appreciated. 



WEIGHT CHART. 
Name, Date of Birth, 191 


E 


o> 


WEEK OF AGE. 


_J 


1 13 26 39 52 


10890 
10430 
9980 
9530 
9070 
8620 
8160 
7710 
7260 
6800 
6350 
5900 
5440 
4990 
4540 
4080 
3630 
3180 
2720 
2270 


































































































24 - 
23 - 
22 ■ 
21 ■ 
20 ■ 
19 - 
18 - 
17 - 
16 - 
15 ■ 
14 ■ 
13 ■ 
12 ■ 
II ■ 
10 ■ 

9 ■ 

8 

7 * 

6 

5 














































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































^ 


























































































f 


*• 














































































































































































































































































y 


























































































^ 




























































































s 






















































































































































































/ 














































































































































































































































































































































































/ 






















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































I 



































































3 MOS. 6 MOS. 9 MOS. 

Fig. 4. — Weight Curve of the First Year. 1 



12 MOS. 



Weight Curve of the First Year. — The curve of the accompanying 
chart is made up from complete weight charts of one hundred healthy 
nursing infants who were thriving and weighed every week, and the in- 
complete charts of about three hundred other infants. There are repre- 



1 Blank weight charts are made by Geo. L. Goodman & Co., 101 Beekman Street, 
New York. 

3 



IS GROWTH AND DEVELOPMENT. 

Bented in round numbers ahoul twenty thousand observations on children 
under one year. The period o( most rapid increase is during the first 
three months. It is slowest from the sixth to the ninth month. This 
curve is not to be regarded as a normal line, like the normal line of the 
temperature chart, but as an average line. An infant who is at birth a 
pound above the average may keep this distance above the line for the 
whole year; another, weighing one pound less than the average, may be 
as far below it. Girls throughout the year are on the average half a 
pound lighter than boys. -No single child exactly follows the line all 
the way. but it is surprising how close to it a very large number of the 
cases come. 

In artificially-fed infants — provided the feeding is properly done — the 
curve does not differ essentially from that of breast-fed infants, except- 
ing in the slower gain of the first month, although this difference is 
usually made up before the sixth month is reached. 

At the end of the first year the average child weighs nearly three 
times as much as at birth. Perfect health during the first year is seen 
only in children who are gaining steadily in weight. A child may not 
always gain rapidly, but it should gain steadily, and if it does not, some- 
thing is wrong. All the conditions surrounding the infant should be 
investigated, but especially the food. One should not be satisfied unless 
the average weekly gain during the first six months is at least four 
ounces. In the second six months it may be slightly less. As a rule, a 
child who gains regularly in weight is thriving; an exception must, how- 
ever, be made in the case of some infants who are fed chiefly upon carbo- 
hydrate foods. 

Weight from the Second to the Fifth Year. — Comparatively few obser- 
vations have been published upon the weight during this period. From 
nearly one thousand personal observations it appears that the normal 
gain of a healthy child is about six pounds during the second year, about 
five during the third year, and about four pounds during the fourth 
year; the actual weights are given in the large table on page 
20. During this period the gain is rarely uniform after the first year. 
With most children it is slowest or the weight is stationary in the sum- 
mer months, while the most rapid increase is usually seen in autumn. 
Throughout this period the girls gain in about the same ratio as boys, but 
remain on the average nearly one pound lighter. Durino- almost every 
illness, no matter of what character, the gain in weight ceases, and usu- 
ally there is a loss, the rapidity and extent of which are somewhat pro- 
portionate to the severity of the attack; but it is alwavs much more 
rapid in diseases of the digestive tract than in any other form of illness. 

Weight of Older Children.— The weights given in the table of children 
from five to fourteen years are from Bowditch. Observations were made 
upon children of American parentage in the public schools of Boston — 



HEIGHT. 



19 



upon 4,327 boys and 3,681 girls. 1 It is to be remembered that these 
weights include the ordinary clothing, while those below five years are 
without clothing. 2 

The slowest gain is from the fifth to the eighth year, when it is about 
four pounds a year. From the eighth to the eleventh year it rises to 
about six pounds a year. Up to the eleventh year the two sexes gain 
in about the same ratio. From the eleventh to the thirteenth year the 
girls gain much more rapidly, passing the boys for the first time and 
maintaining this lead until the fifteenth year, when again the boys 
pass them. 

HEIGHT. 

The figures showing the height at different ages are given in the fol- 
lowing table. The measurements of infants at birth are taken in about 
equal numbers from the records of the New York Infant Asylum and 
the Sloane Maternity Hospital. They were made upon full-term infants. 

Average length of 231 males 20.61 inches (52.5 cm.); 

" " 211 females 20.47 " (52.2 " ); 

442 infants 20.54 " (52.35 " ). 

The most rapid gain in length is in the first year. During this period 
the child grows on an average a little over eight inches (21 cm.). This 
gain is usually, but not always, proportionate to the increase in weight. 
During the second year the average increase is three and a half inches (9 



1 W. T. Porter has published (1894) observations made upon 14,744 children of 
American parentage in the public schools of St. Louis. His figures show quite a 
variation from those of Bowditch, and are as follows: 



Age. 


boys' weight. 


GIRLS WEIGHT. 


Kilos. 


Pounds. 


Kilos. 


Pounds. 


6 years 


19.66 
21.67 
23.91 
26.08 
28.49 
31.26 
33.45 
35.96 
40.34 
47.25 
52 . 10 


43.2 
47.7 
52.6 
57.4 
62.7 
68.8 
73.6 
79.1 
88.7 
103.9 
114.6 


18.76 

20.82 
22.71 
25.07 
27.43 
29.93 
33.17 
38.29 
43.12 
46.90 
50.06 


41.3 


7 " 


45.8 


8 " 


50.0 


9 " 


55.1 


10 " 


60.3 


11 " 


65.8 


12 " 


73.0 


13 " 


84.2 


14 " 


94.9 


15 " 


103.2 


16 " 


110.1 







2 The average weight of the ordinary house clothing of school children, according 
to Bowditch, is at five years, 2.8 pounds for both sexes; at seven years, 3.5 for both 
sexes; at ten years, 5.7 pounds for boys and 4.5 pounds for girls; at thirteen years, 7.4 
pounds for boys and 5.6 pounds for girls; at sixteen years, 9.7 pounds for boys and 8.1 
pounds for girls. This must be deducted from weights given to obtain the net weight. 



'20 



GROWTH AND DK\ KLOl'MENT. 



Table stowing Weight, Height, and Circumference of tfw Head a?id Chest from 
Birth to the Sixteenth Year. 1 







u BIQHT. 


HK1CHT. 


CHEST. 


HEAD. 






Pounds. 


K il< >-. 


Inches. 


Cm. 


Inches. 


Cm. 


Inches. 


Cm. 


Birth 


Boys. 

Girls. 


7.55 

7. hi 


3.43 
3.26 


20.6 

20.5 


52.5 

52.2 


13.4 

13.0 


34.2 

33.2 


13.9 

13.5 


35.5 

34.5 


6 months*. 


Boys. 
Girls. 


16.0 
L5.5 


7.26 
7.03 


25.4 

25.0 


64.8 

63.6 


16.5 

16.1 


42.0 

41.0 


17.0 

16.6 


43.5 

42.2 


12 months 2 . 


Boys. 
Girls. 


21.0 
20.5 


9.29 

S.S4 


29.0 

28. 7 


73.8 
73.2 


18.0 

17.4 


45.9 

44.4 


18.0 

17.6 


45.9 

44.6 


IS months-. . 


Boys. 

Girls. 


24.0 

23.0 


10.35 

9.98 


30.0 

29.7 


76.3 

75.6 


18.5 

18.0 


47.1 

45.9 


18.5 

18.0 


47.1 

45.9 


2 years : . . . . 


Boys. 

Girls. 


27.0 

26.0 


12.02 

11.56 


32.5 

32.5 


82.8 
82.8 


19.0 

18.5 


48.4 

47.0 


18.9 

18.6 


48.2 
47.2 


3 yean : 


Boys. 

Girls. 


32.0 

31.0 


14.14 

13.60 


35.0 

35.0 


89.1 

89.1 


20.1 

19.8 


51.1 

50.5 


19.3 

19.0 


49.0 

48.4 


4 yean 


Boys. 

Girls. 


36.0 

35.0 


15.87 

15.41 


38.0 

38.0 


96.7 

96.7 


20.7 

20.7 


52.8 
52.2 


19.7 

19.5 


50.3 

49.6 


5 years 


Boys. 
Girls. 


41.2 

39.8 


18.71 

18.06 


41.7 

41.4 


106.0 

105.3 


21.5 

21.0 


54.8 

53.5 


20.5 

20.2 


52.2 

51.3 


6 years 


Boys. 

Girls. 

Boys. 
Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 


45.1 

43.8 

49.5 

48.0 

54.5 

52.9 

60.0 

57.5 

66.6 

64.1 


20.48 

19.87 

22.44 

21.78 

24.70 

24.01 

26.58 

26.10 

30.22 

29.07 


44.1 

43.6 

46.2 

45.9 

48.2 

48.0 

50.1 

49.6 

52.2 

51.8 


112.0 

110.9 

117.4 

116.7 

122.3 

122.1 

127.2 

126.0 

132.6 

131.5 


23.2 

22.8 

23.7 

23.3 

24.4 

23.8 

25.1 

24.5 

25.8 

24.7 


59.1 

58.3 

60.6 

59.5 

62.2 

60.8 

63.9 

62.5 

65.6 

63.0 






















8 years 










9 years 










10 years. . . . 


21.0 

20.7 


53.5 

52.8 


11 years 


Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 
Girls. 


72.4 

70.3 

79.8 

81.4 

88.3 
91.2 

99.3 

100.3 

110.8 

108.4 


32.83 

31.S7 

36.21 

36.90 

40.04 

41.36 

45.03 

45.50 

50.26 

49.17 


54.0 

53.8 

55.8 
57.1 

58.2 
58.7 

61.0 

60.3 

63.0 

61.4 


137.2 

136.6 

141.7 

145.2 

147.7 

149.2 

155.1 

153.2 

159.9 

155.9 


26.4 

25.S 

27.0 

26.8 

27.7 

28.0 

28.8 
29.2 

30.0 

30.3 


67.2 

65.8 

68.8 
68.3 

70.6 

71.3 

73.3 

74.1 

76.6 

76.8 










12 years 










13 years 










14 years 










15 years 


21.8 

21.5 


55.5 

54.8 


16 year 


Boys. 

Girls. 


123.7 
113.0 


56.09 

51.24 


65.6 

61.7 


166.5 

156.7 


31.2 

30.8 


79.2 

78.8 

















(Science, April 12, 1895) upon 4,319 children over six 
exceed children born at a later period both in height 



1 The observations of Boas 
years old show that first born 
and weight. 

2 These weights are without clothes; after five years clothes are included 



THE HEAD. 21 

cm.). From this time on the rate of increase is quite uniform in both 
sexes until the eleventh year, it being between two and three inches a year. 

After the eleventh year in girls and the twelfth in boys the growth is 
much more rapid. In height the girls exceed the boys at the twelfth 
and thirteenth years for the only time in their growth. 

In the figures given in the preceding table those of five years and over 
are taken from Bowditch, the observations being made upon the same 
children as those whose weights were taken. The observations from six 
months to four years inclusive are from original sources, and are drawn 
from about five hundred cases. The height much more than the weight 
of children is modified by hereditary influences. 

Rachitic children during infancy and early childhood are, as a rule, 
shorter than others. I have frequently measured such children during 
the third year who were six inches below the average for that age. The 
effect of malnutrition upon the length of the body is much less than 
upon the weight. 

GROWTH OF THE EXTREMITIES AS COMPARED WITH THE TRUNK. 

At birth the trunk is relatively long and the extremities short. The 
centre of the body at birth, according to one hundred observations made 
for me by Dr. Wilbur Ward at the Sloane Maternity Hospital, is three- 
quarters of an inch (2 cm.) below the centre of the umbilicus. Sub- 
sequently the growth of the extremities is much more rapid than that 
of the trunk. Thus I have found at birth the length of the lower ex- 
tremities (measuring from the anterior superior spine of the ileum to 
the sole of the foot) to be forty-three per cent of the length of the body; 
at five years, fifty-four per cent, and at sixteen years, sixty per cent. The 
above figures are from one hundred and fifty observations, which, al- 
though not numerous enough for exact percentages, are still sufficient 
to give a very good idea of the general relation of the length of the ex- 
tremities to that of the body as a whole. These facts are of some assist- 
ance in the diagnosis of diseases attended by abnormalities of growth, 
such as rickets, cretinism, and chondrodystrophy. 

THE HEAD. 

Circumference. — The average circumference of the head at birth in 
four hundred and forty-six full-term infants observed at the Sloane 
Maternity Hospital and New York Infant Asylum was as follows : 

Average circumference of the head, 231 males 13.90 inches (35.5 cm.); 

" 215 females. ...13.52 " (34.5 " ); 

Total 446 infants. . . . 13.71 " (35.0 " ). 

The occipito-frontal measurement was the one taken. 



22 OWTH AND DEVELOPMENT. 

The growth o( the head is most rapid during the firsl year, the in- 
■ being about four inches (10 cm.). It is about half an inch a 
month during the early months, and a fourth of an inch a month dur- 
ing the later months of the firsl year. During the second year the 
a about one inch (2.5 cm.). From the second to the fifth year 
rowth is slower, being only about one and a half inches (4 cm.) for 
the three years. After the fifth year the increase in the circumference 
of the head is very slow (see table). 

Closure of the Sutures. — The main sutures of the cranium are not 
commonly ossified before the end o( the sixth month, and very frequently 
some mobility may lie detected at the end of the ninth month. Distinct 
separation of the cranial hones after birth is abnormal. It is most fre- 
quently seen in premature and in syphilitic infants. 

Closure of the Fontanels. — The posterior fontanel is usually oblit- 
erated by the end of the second month. The anterior fontanel under 
normal conditions closes on an average at about the eighteenth month. 
The usual variations are between the fourteenth and twenty-second 
months. At the end of the first year the fontanel is generally about 
one inch in diameter. An open fontanel at the end of the second year 
may be considered abnormal. The closure of the fontanel is not al- 
ways early in well-nourished children, nor is it always delayed in those 
suffering from malnutrition. In very rare cases the anterior fontanel 
may either be closed at birth or may close during the first few weeks of 
life. Closure of the fontanel by the middle of the first year is often seen 
in cases of arrested cerebral development. This indicates a serious con- 
dition, usually microcephalus. Closure of the fontanel in the early 
months of the second year may be due to the slow growth of the 
brain in a child suffering from general malnutrition but otherwise 
normal. 

By far the most frequent cause of delayed closure of the fontanel is 
rickets, in which condition it may be open up to the end of the third 
year. A large fontanel is one of the striking features of cretinism, and 
in untreated cases is often seen as late as the eighth year or later. In 
infancy an open fontanel with a rapid growth of the head should at 
once suggest hydrocephalus. There is an hereditary condition in which 
the fontanel remains open even to adult life. Two such cases in father 
and son were shown me by Marie in Paris. In both there was also lack 
of union between the two portions of the clavicle. 

Shape of the Head. — The deformity which results from compression 
during labour usually disappears by the end of the first month. During 
the first year the head often becomes flattened at the occiput in conse- 
quence of the child's lying too much upon the back. This is easily 
remedied by changing his position. A slight obliquity of the head may 
result from a habitual position during nursing or sleep. A marked de- 



THE CHEST. 23 

gree of obliquity is sometimes congenital, but usually disappears by the 
third or fourth year. 

The other abnormities in the shape of the head are chiefly due to 
rickets and hydrocephalus, more rarely to congenital malformations of 
the brain. They will be considered in the chapter devoted to these topics. 

Premature ossification of the sutures of the cranium occasionally gives 
rise to a very striking deformity of the head. I have seen two cases of 




Fig. 5. — Premature Ossification of the Sagittal Suture. Death at six weeks. 

such deformity from premature ossification of the sagittal suture. The 
heads in both cases were very narrow and long in the antero-posterior 
diameter. The forehead was narrow, prominent, and slightly project- 
ing. The illustration on this page shows the skull of one of' these cases. 
There is a complete "obliteration of the sagittal suture. In this case 
there was a wide separation of the sutures at the junction of the parietal 
and temporal bones. 

THE CHEST. 

The figures showing the circumference of the chest at the different 
periods of childhood have already been given. The measurements up to 



24 GROWTH AND DEVELOPMENT. 

and including five years are from personal observations, those from the 
sixth bo the sixteenth are taken from Porter, and are drawn from obser- 
vations on 31,3? 1 Bchool children. The measurement of the chest is that 
taken midway between full inspiration and expiration, and at the level 

the nijm 

In the newly-born child the anteroposterior and the transverse diam- 

>f the chesl are nearly the same. As age advances, the transverse 

diameter increases very much more rapidly, so that the outline of the 

chest gradually assumes an elliptical shape, which it maintains during 

childhood 

At birth, the circumference of the chest is about one-half inch less 
than that of the head, hut throughout infancy the two measurements 
are nearly the same. It is not until the third year that the average 
circumference of the chest exceeds that of the head. The chest measure- 
ment in infants is always much modified by the amount of fat; but, after 
making due allowance for this, a large chest always indicates a robust 
child and a small chest a delicate one. If at any age the circumference 
of the child's chest is found to be below the average, means should be 
taken, by gymnastics and otherwise, to develop it. 

In infants deformities of the thorax result chiefly from rickets, some- 
times from empyema, emphysema, and cardiac disease ; in older children, 
from lateral curvature of the spine, or from Pott's disease. A peculiar 
deformity, usually congenital, but sometimes rachitic, is the funnel- 
shaped chest, the Trichtcr-brust of the Germans. It consists in a deep 
pit-like central depression at the lower end of the sternum. It is usually 
permanent. 

THE ABDOMEN. 

Throughout infancy the circumference of the abdomen is, as a rule, 
about the same as that of the chest. At the end of the second year 
the measurements of the head, chest, and abdomen are very often identi- 
cal; after this time the chest measurement increases much more rapidly 
than the other two. Marked enlargement of the abdomen is seen in 
many varieties of chronic intestinal disorders. It is, however, most 
marked in the tympanites which so constantly accompanies rickets. 

MUSCULAR DEVELOPMENT. 

The first voluntary movements are usually in the fourth month, when 
the infant deliberately attempts to grasp some object placed before it. 
During the fourth month, as a rule, the head can be held erect when the 
trunk is supported. In many infants this is possible in the early part 
of the third month. At seven or eight months a healthy child is usually 
able to sit erect and support the trunk for several minutes. 

in the ninth or tenth month are usually seen the first attempts to 



DEVELOPMENT OF THE SPECIAL SENSES. 25 

bear the weight upon the feet. At eleven or twelve months a child 
usually stands with slight assistance. The first attempts at walking are 
commonly seen in the twelfth or thirteenth month. The average age at 
which children walk freely alone has been, in my experience, the four- 
teenth or fifteenth month. Quite wide variations are seen in healthy 
children. Very much depends upon the surroundings. I have known 
infants to walk at ten months and many others not until seventeen or 
eighteen months, although showing no evidences of disease, and although 
their development had not been retarded by previous illness. A very 
marked difference is seen in different families with respect to the time 
of walking. 

The physician is often consulted because of backward muscular devel- 
opment, most frequently because the child is late in walking. General 
malnutrition, or any other severe or prolonged illness, may postpone for 
several months this or any of the other functions mentioned. When 
there is no such explanation of the backwardness, a child who does not 
hold up his head, sit alone, or make efforts to stand or walk at the proper 
time, should be submitted to a careful examination for mental deficiency 
or cerebral or spinal paralysis, but especially for rickets which is the 
most frequent explanation of the symptoms. 

Contrivances for teaching infants to walk are unnecessary, and their 
effect may even be injurious. An infant should be allowed the greatest 
possible freedom in the use of his limbs. He should not be restrained 
from walking when inclined to do so, nor continually urged to walk when 
no voluntary attempts are made. Nothing short of mechanical restraint 
will prevent a healthy child from walking or standing when he is strong 
enough to do so. 

DEVELOPMENT OF THE SPECIAL SENSES. 1 

Sight. — The newly-born infant avoids the light. The pupils contract 
in a light room, and if a bright light is brought before the eyes they 
close. During the first few weeks the infant indicates by every sign that 
excessive light is unpleasant. As early as the sixth day the eyes will 
sometimes follow a light in the room, and the child may even turn the 
head for this purpose. The muscles of the eyes of the newly-born infant 
act irregularly and not in harmony. Co-ordinate action for general pur- 
poses is not established until about the end of the third month. Even 
after this time inco-ordinate action is occasionally seen. The eyelids 
also move irregularly, and are often partly separated during sleep. The 
cornea is but slightly sensitive during the first weeks. In Preyer's child 
it was not until the third month that the lids closed when the water in 

1 For many of the facts in this paragraph I am indebted to Preyer's The Senses 
and the Will, American edition, D. Appleton and Company. 



26 GROWTH AND DEVELOPMENT. 

the bath touched the lashes or the eornea. The recognition of objects 
seen is usually evident in the sixth month. 

It is important that the room in which the newly-born child is placed 
should be darkened, and that for the first few weeks the eyes should be 
protected against strong light. 

Hearing. — For the first twenty-four hours after birth infants are 
deaf. This deafness sometimes persists for several days. It is believed 
to be due to absence of air from the middle ear and to swelling of the 
mucous membrane which lines the tympanum. With the movements of 
respiration, air gradually finds its way into the middle ear, and the swell- 
ing subsides during the first few days. After this the hearing gradually 
improves, and during the early months of life it is very acute. The child 
starts at the slamming of a door, and even moderately loud noises will 
waken him from sleep. By the end of the second month he will some- 
times turn his head in the direction from which the sound comes, and 
by the end of the third month this will usually be done. Demme found, 
in observations upon one hundred and fifty infants, that the voices of 
parents were recognised on an average at three and a half months. 

Not only are the ears unusually sensitive to sound in infancy, but 
the impression produced upon the brain is often marked — very loud 
sounds causing great fright, and sometimes even, it is reported, con- 
vulsions. 

Touch. — Tactile sensibility is present at birth, but is not highly devel- 
oped except in the lips and tongue, where it is very acute for the obvious 
necessity of sucking. After the third month it is fairly acute over the 
surface of the body generally. Two especially sensitive areas, according 
to Preyer, are the forehead and external auditory meatus. 

Sensibility to painful impressions is present in early infancy, but 
very dull as compared with later childhood. 

Temperature is also distinguished. This recognition is especially 
acute in the tongue. A young infant is often seen to refuse to take the 
bottle because the milk is only a few degrees too cold or too warm. 

The localisation of sensory impressions comes later, probably not 
much before the middle of the sixth month, and is very imperfect 
throughout the first year. 

Taste. — This is highly developed, even from birth. According to the 
experiments of Kussmaul, the ability to distinguish sweet, sour and bit- 
ter, exists in the newly-born child — sweet exciting sucking movements, 
and bitter, grimaces. A young infant detects with surprising accuracy 
the slightest variation in the taste of its food, and the smallest difference 
is often enough to cause it to refuse the bottle altogether. Sweet sub- 
stances are always easily administered, and in combination with sirups 
even very bitter substances can be given; but to aromatic powders and 
elixirs he usually objects. 



DENTITION. 27 

Smell. — Observations upon the sense of smell in newly-born infants 
are few and not altogether conclusive. Kroner's experiments appear to 
show that smell is present in the newly born. It has been noted to be 
especially acute in infants born blind. The sense of smell is developed 
much later than the other senses. Detection of fine differences in odours 
is not acquired until quite late in childhood. 

SPEECH. 

There is a very wide variation in children with reference to the time 
of development of the function of speech. Girls, as a rule, talk from 
two to four months earlier than boys. Towards the end of the first 
year the average child begins with the words " papa/' " mamma." By 
the end of the second year he is able to put words together in short 
sentences of two or three words. Progress in speech from this time is 
very rapid, each month showing great improvement. Names of persons 
are commonly first acquired, then the names of objects. Next to this 
the verbs are learned, and then adverbs and adjectives. Conjunctions, 
prepositions, and articles follow in order, and last of all the personal 
pronouns. 

If a child of two years makes no attempt to speak, some mental defect 
may usually be inferred or that the child is a deaf mute. 

DENTITION. 

The teeth are enclosed at birth in dental sacs which are situated in 
the gums. Superficially they are covered by the submucous connective 
tissue and the mucous membrane; the dental sacs rest in depressions in 
the alveolar process of the jaw. The tooth grows in length mainly as the 
result of the calcification of its roots, and being thus fixed below, it 
pushes upward towards the mucous membrane. This growth undoubtedly 
goes on steadily from birth until the tooth pierces the gum. 

The deciduous or milk teeth are twenty in number. The time at 
which they appear is subject to considerable variation even under normal 
conditions. The following is the order and the average time of appear- 
ance of the different teeth: 

(1) Two lower central incisors 6 to 9 months. 

(2) Four upper incisors 8 " 12 

(3) Two lower lateral incisors and four anterior molars. ... 12 " 15 " 

(4) Four canines 18 " 24 

(5) Four posterior molars 24 " 30 " 

At 1 year a child should have 6 teeth. 

AtlJ " " " " 12 " 

At 2 years " " " 16 " 

At 2\ " " " " 20 " 



28 GROWTH AND DEVELOPMENT. 

Quito wide variations on both sides of the average are common, and 
are not always easy of explanation. In many cases it seems to be a family 
idiosyncrasy, since in the different members of a family the teeth are 
apt to appear at about the same time. The order in which the teeth 
appear is much more regular than the time of their appearance. Slight 
variations are exceedingly common, but marked irregularities in the 
order of the appearance of the teeth are the rule in idiotic children or 
those suffering from slighter mental defects. 

The teeth may pierce the gum without any local manifestations. 
Very frequently, however, just before a tooth comes through there is 
noticed a moderate swelling and redness of the mucous membrane of the 
gum overlying it, and to a slight degree this may affect the general 
mucous membrane of the mouth. This condition may be accompanied 
by a little fretfulness and increased salivation, or both of these may be 
entirely wanting. These symptoms usually disappear when the tooth 
has pierced the gum. The symptoms of difficult dentition will be dis- 
cussed in connection with Diseases of the Mouth. 

Infants may be born with teeth. I know of one family in which 
this occurred in three members of three successive generations. It is, 
however, rare. It is almost invariably one of the low r er central incisors 
that is present. In case this interferes with nursing, or if it is very 
loosely attached to the gum, it should be extracted, but under other 
circumstances it should be allowed to remain, since, if it is removed, 
a second tooth is not likely to appear in its place in the first set. It is 
not at all uncommon for the first teeth to appear in the fourth month. 
Such teeth, in my experience, do not usually differ in character from 
those appearing later, unless they are in children who are syphilitic. 
Syphilitic children are rather prone to early dentition, and under such 
circumstances rapid and early decay is likely to take place. Nursing 
infants are, as a rule, a little earlier in their dentition than those arti- 
ficially fed. 

Delayed dentition is usually due to rickets. However, in many 
healthy infants no teeth appear before the tenth month; and I have 
occasionally seen the first ones at thirteen months in those who seemed 
perfectly healthy and showed no other evidence of rickets. On the other 
hand, it is by no means invariable that dentition is late in rachitic chil- 
dren. The latest dentition is seen in cases of cretinism. In such chil- 
dren it is not rare for the first teeth to appear as late as eighteen 
months or two years. As a rule, dentition and ossification of the bones 
of the head go on in a corresponding manner; where one is early the 
other is likely to be rapid, and conversely. Great irregularities in denti- 
tion are common in children with defective cerebral development. 

Provided an infant is well nourished and thrives properly for the 
first six or eight months, the eruption of the teeth is likely to go on 



PECULIARITIES OF DISEASE IN CHILDREN. 29 

steadily after this time, even though the child may later have chronic 
indigestion or suffer from extreme malnutrition from any cause excepting 
rickets. If, however, the symptoms of malnutrition date from birth, 
dentition is almost invariably delayed. It is often a matter of very 
great surprise to see children who are markedly emaciated as a result of 
chronic indigestion or ileo-colitis and yet go on cutting their teeth reg- 
ularly. I once had under my care a delicate infant of sixteen months, 
whose body length was twenty-eight inches and whose weight was less 
than nineteen pounds — almost exactly what they were eight months 
previously — and yet he had thirteen teeth. 

Eruption of the Permanent Teeth. — The first to appear are the first 
molars, which usually come in the sixth year, and hence the name six- 
year-old molars, which is applied to them. These appear posterior to the 
second molars of the first set. The following table from Forchheimer 
gives the average time of the appearance of the second teeth : 

First molars 6 years. 

Incisors 7 to 8 

Bicuspids 9 " 10 

Canines 12 " 14 

Second molars 12 " 15 

Third molars 17 " 25 

The incisors and canines replace the corresponding teeth of the first 
set. The eight bicuspids take the place of the eight molars of the first 
set. The molars of the permanent set appear back of the bicuspids, room 
being made for them by the growth of the jaw. As they grow and push 
upward they cause atrophy of the roots of the first teeth, and gradually 
cut off their blood supply, so that they loosen and fall out. 

The place of dentition as an etiological factor in the diseases of in- 
fancy will be considered in the chapter on Difficult Dentition. 



CHAPTER III. 
PECULIARITIES OF DISEASE IN CHILDREN. 

In many particulars disease in children differs from that of later life. 
These differences relate to etiology, pathology, symptomatology, diagno- 
sis, and prognosis. The greatest contrast to adult life is presented by 
infancy and early childhood. After seven years, children in their dis- 
eases resemble adults more than they do infants. 

ETIOLOGY. 
1. Inheritance is an important factor. The disease most frequently 
transmitted directly is syphilis. Occasionally tuberculosis and other 



30 PECULIARITIES OF DISEASE IN CHILDREN. 

infectious diseases have been conveyed directly from the mother to the 
child. In cases where no distinct disease is transmitted, children may 
inherit from parents constitutional weaknesses or tendencies, which may 
manifest themselves in infancy, or in some cases not until later child- 
hood, ruder this head we may place the influence of alcoholism, lead 
poisoning, rheumatism, gout, epilepsy, and insanity. 

v\ Malformations must be considered, particularly in the first two 
years of life. The most important of these, from a medical standpoint, 
are those of the heart, brain, stomach and intestines, and kidney. The 
various malformations of the mouth, nose, bladder, rectum, and genital 
organs belong more particularly to the domain of surgery. 

3. The Diseases or Accidents Connected with Birth. — Some of these 
are distinctly traumatic, like the meningeal haemorrhages. A very large 
class are the infectious processes in the newly born. Infection usually 
takes place through the umbilical wound, more rarely through the skin 
or mucous membranes. This class includes pyaemia, with its varied 
lesions in the brain, lungs, and serous membranes, erysipelas, ophthalmia, 
and tetanus. In the class of infectious diseases may also be included 
many of the varieties of pulmonary and intestinal diseases in the newly 
born, and probably also some of the hasmorrhagic affections. 

-1. Conditions Interfering with Proper Growth and Development. — 
These are among the largest etiological factors in the diseases of infancy. 
They are improper food or feeding, unhygienic surroundings, and neglect. 
These may cause specific diseases, like rickets or scurvy, or may lead to a 
condition of general malnutrition or marasmus. In this way they become 
most important predisposing factors, in infancy, to the acute diseases of the 
gastro-enteric tract, and later in childhood, to functional nervous diseases. 

5. Infection. — This has already been mentioned as an important fac- 
tor in diseases of the newly born. The number of diseases in later life 
directly traceable to this is very^ large. Under this head should be in- 
cluded not only the well-known classes of infectious and contagious dis- 
eases, but also a very large number of varieties of infection which as yet 
have not been differentiated, and the nature of which is but imperfectly 
understood. 

SYMPTOMATOLOGY AND DIAGNOSIS. 

In older children the symptoms of disease are very much the same as 
in adults, and similar methods of examination may be employed. What 
is really peculiar to children belongs especially to the first three years of 
life, before speech has developed. During this period the chief and 
almost the sole reliance of the physician must be upon the objective 
signs of the disease. It is not so much that diseases in early life are 
peculiar, as that the patients themselves are peculiar. 

Two fundamental facts are always to be kept in mind : First, that the 



SYMPTOMATOLOGY AND DIAGNOSIS. 31 

common pathological processes are comparatively few, being chiefly of 
the gastro-enteric tract, the lungs, and the brain, but that the variations 
in clinical types are almost endless; the second is, that in infants, on 
account of the susceptibility of the nervous system, functional derange- 
ments are often accompanied by very grave symptoms, and may even 
prove fatal in twelve or twenty-four hours, or there may be speedy and 
complete recovery after very alarming symptoms. In many of these 
cases the symptoms are so indefinite that an exact diagnosis is impossible 
during life, and even the autopsy may throw but little light upon them. 

At the bedside it is of great assistance to the physician if he can keep 
in mind the most frequent forms of acute disease that are likely to be 
met with. In the first group, including those which are very common, 
may be placed acute indigestion and ileo-colitis, bronchitis, pneumonia, 
pharyngitis, and tonsillitis; in the second group, including those which 
are less frequent, may be placed otitis and the more common acute infec- 
tious diseases; in the third group, including the rarer forms of acute 
disease — meningitis, tuberculosis, rheumatism, and diseases of the kid- 
neys. Under all circumstances, the season, and the nature of the pre- 
vailing epidemic, if one exists, are to be considered. 

In the examination of a sick infant quite a different method is to be 
followed from that pursued with adults. Much information is to be 
gained from a history carefully taken from an intelligent mother or 
nurse, and much more from a close observation of the child, whether 
asleep or awake, quiet or crying. 

The History. — In view of the fact that but little information can 
be had from the patient, none at all in most cases, it is important to 
obtain from the mother or nurse as full and complete information as 
possible. A good history carefully obtained, puts the physician in pos- 
session of a fund of information about the patient which is not only of 
the greatest value in arriving at a diagnosis in the illness for which he 
is consulted, but is exceedingly helpful in the future management of the 
child. He may thus know the individual peculiarities and special path- 
ological tendencies. The laity attach great importance, and justly so, 
to advice from the physician who " knows the child's constitution." Such 
a history should be taken at the first opportunity after the physician is 
placed in charge of a child, and with note book in hand, or half its value 
will be lost. 

Family History. — This should begin with the parents, going farther 
back, if possible, in many cases of hereditary disease. One must know 
regarding tuberculosis, syphilis, rheumatism, or alcoholism, the general 
vigour of constitution and physical condition of both father and mother. 
Health during pregnancy and previous miscarriages, if any, are im- 
portant facts in the mother's history. One should know the number 
of other children living and their general health, the number dead and 



32 PECULIARITIES OF DISEASE IN CHILDREN. 

from what causes. A knowledge of the surroundings in which the child 
has lived may be necessary to appreciate the chances of exposure to 
tuberculosis, malaria, and many other forms of infection. 

Patient's Previous History. — This should begin with birth. One 
should inquire whether the child was premature or born at term, regard- 
ing the character of the labour, whether natural or instrumental, tedious 
or complicated, the condition and vigour of the child at birth, primary 
respirations, early convulsions, and the nutrition during the early days. 
Next the methods of feeding should be taken up — how long entirely 
and how long partly breast fed, the date of weaning and the form of 
artificial feeding then employed. If the patient is an infant, and the 
problem presented is one of its nutrition, all the reliable data relating 
to the feeding should be obtained, even to the minutest detail. This 
may be wearisome and consume time, but in no other way can one ap- 
preciate the conditions present. The best idea of the child's growth and 
development may be obtained from a weight record if one has been 
kept. If not available, one must depend upon general statements as 
to how the child thrived at different periods. The date of the appear- 
ance of the first teeth and the time and the order in which the teeth 
came, are significant. The general muscular development may be best 
determined by learning when the child could first hold the head erect, 
sit alone upon the floor, bear the weight upon the feet, creep or walk 
alone; the mental development, by learning as to early recognition of 
mother or nurse, knowing the bottle, understanding the meaning of 
words, speaking in words or sentences. The muscular and mental devel- 
opment of a normal child during the first two years is a subject with 
which the physician should be familiar if he would detect early those 
differences, often slight at this age, in children whose development is 
backward owing to cerebral lesions. 

All previous attacks of acute illness of whatever character should be 
noted, particularly the infectious diseases — measles, scarlet fever, diph- 
theria, pertussis, and influenza — with dates and details as to duration, 
severity, and complications. One should learn whether the child is espe- 
cially prone to disorders of digestion or those of the respiratory system. 
Under the former head are included early difficulties in feeding, acute 
attacks of indigestion, diarrhoea, or dysentery, also chronic disturbances 
of the stomach or bowels; under the latter head, frequent catarrhal 
colds, earache or otitis, catarrhal croup, bronchitis, pneumonia, or 
pleurisy. Other points to be investigated relate to attacks of tonsillitis, 
operations for the removal of hypertrophied tonsils or adenoids, and 
previous disorders of the nervous system. In infants, particularly im- 
portant are extreme restlessness, insomnia, convulsions, or attacks of 
night terrors ; in those who are older, hysterical manifestations, epilepsy, 
or chorea. Finally, one should know the date of successful vaccination. 



SYMPTOMATOLOGY AND DIAGNOSIS. 33 

Inquiry should also be made concerning any recent exposure to infection 
in the community, school, or home. 

Present Illness. — One should first note the chief complaints as stated 
by mother or nurse. It is important to obtain as definite statements as 
possible as to the time when the child was quite well, and whether the 
onset of the illness was abrupt or gradual, and with what particular 
symptoms. In all digestive disorders one should know exactly concern- 
ing the child's food at the time of the onset, its quantity, character, and 
preparation; also any recent change in diet, the presence or absence of 
vomiting, and the condition of the bowels, whether loose or constipated, 
the frequency and character of the stools. General questions as. to 
whether the bowels are regular or the stools normal are of no value, 
since the informant often is not capable of judging correctly. 

Nervous symptoms, like the others, should be elicited in response to 
direct questions regarding sleep, restlessness, moaning, crying out, or 
other evidences of pain, excitement, delirium, or convulsions, or unnat- 
ural drowsiness. In any acute illness other important symptoms are 
fever, sweating, dyspnoea, cough, hoarseness, nasal discharge, and the 
amount and character of the urine. 

The Examination. — With infants, quite a different method should be 
followed from that pursued with adults. It may well begin with : 

General Inspection. — What is learned in this way will depend almost 
entirely upon the acuteness of observation of the physician, but much 
that is of value can be ascertained before the clothing is removed for the 
physical examination by simply watching the patient, whether asleep or 
awake, for several minutes. In acute disease, the following points should 
be noted especially: 

1. Nutrition and general development: whether the child is well 
nourished or the features pinched and washed. 

2. The facial expression : whether it is bright and intelligent or dull 
and stupid, peaceful or anxious, quiet or disturbed, and whether the 
features are contracted from time to time, as if from pain. 

3. The character of the respiration : whether it is rapid or slow, easy 
or difficult; whether there is nasal obstruction, as indicated by snoring 
and mouth-breathing, suggesting in infants acute rhinitis, syphilis, or 
retro-pharyngeal abscess; in older children, diphtheria, scarlet fever, or 
adenoids. Marked dyspnoea is usually accompanied by active dilatation 
of the alae nasi. 

4. The posture : whether the child lies upon the back, side, or face ; 
whether the head is drawn back with general flexion of the extremities 
as in meningitis. 

5. The nervous condition : whether the child is restless, excitable, or 

drowsy and apathetic; if asleep, the nature of the sleep should be 

observed. 

4 



34 PECULIARITIES OF DISEASE IN CHILDREN. 

(5. The colour of the skin of the face: whether pale or cyanotic; and 
the lips, whether fissured or excoriated. 

7. The amount of prostration: a practised eye can usually tell with 
older children whether the condition is grave or not, but infants not 
infrequently deceive even the most experienced observer. 

8. The cry : in conditions of restlessness or irritability, much infor- 
mation may be obtained from its character. It is important, but not 
always easy, to determine whether a child cries from fright, as at the 
approach of a stranger, from nervousness or bad training, from general 
irritability which may come from any acute disease, or from actual 
pain. The cry of fright is usually evident, because it comes with the 
physician's approach and ceases when he goes away. Children of highly 
neurotic parents and those who have been much indulged and badly 
trained will often cry when anything out of the usual routine occurs. 
The cry of pain may be very distinctive ; it may be sharp and acute and 
accompanied by some attempt at localisation, as when a child puts his, 
hand to an inflamed part, but in infancy the pain of acute inflammation 
is often indicated only by general restlessness and irritability. This is 
frequently true of acute otitis. The cry of pain is usually accompanied 
by contraction of the features and other evidences of distress. 

The cry of some diseases is quite characteristic, as the short, catchy 
cry of acute pneumonia or bronchitis; the hoarse cry of laryngitis, 
whether catarrhal, membranous, or syphilitic; the feeble whine of ex- 
treme exhaustion or marasmus; the moaning cry of intestinal disease; 
and the sharp cry of a child with scurvy whenever its bed or body is 
touched. 

Measurements. — These, though of greatest value in chronic diseases, 
particularly disturbances of nutrition, may be of assistance also in acute 
conditions. The important measurements are the circumference of the 
head, chest, and body length. The circumference of the abdomen is at 
times important, but varies so much with the degree of distention that 
it is not significant as to the general development. The measurements 
and weight furnish reliable data which are not only of assistance in the 
diagnosis of existing disease, but if recorded are useful for future com- 
parison. 

In taking the circumference of the head the largest measurement 
(over the occipital and frontal eminences) is preferable. The measure- 
ment of the chest is usually taken over the nipples. The body length 
of infants is best taken with a tape as the child lies upon his back upon 
a table or a firm bed. For older children a special measuring stick is 
convenient. 

To estimate properly the significance of measurements they should 
be compared with the normal averages and with each other. It should 
be remembered that the head is normally larger than the chest until near 



SYMPTOMATOLOGY AND DIAGNOSIS. 35 

the end of the second } r ear; after this time, with a normal development, 
the chest should be larger. Any great disproportion between the. size 
of the head and chest is suggestive of disease. The large head and the 
small chest belong especially to rickets. The measurements form impor- 
tant means of recognising early such abnormalities as cretinism and 
achondroplasia, the variations often being marked before the other symp- 
toms are prominent. One who forms the habit of taking regular meas- 
urements soon appreciates the variations from the normal, and gains 
great assistance from these data. Such a record made from year to 
year in children whose development is in any way abnormal is of great 
value in indicating what should be done in the way of exercise to correct 
faulty conditions. 

Vital Signs. — Pulse, Eespiration, and Temperature. — The signifi- 
cance of these signs is not to be measured by adult standards, since the 
susceptible nervous system of infants and very young children greatly 
exaggerates their reaction to all forms of acute infection. 

The rate, regularity, quality, and tension of the pulse should be noted. 
In young children, the rate of the pulse is of less importance than its 
force and quality. A slow, irregular pulse is always significant, and 
should suggest meningitis or brain tumour; an irregular pulse, when 
rapid, has no special significance. The pulse rate is much increased 
from slight disturbances; the approach of the stranger or the examina- 
tion by the physician may cause it to rise 20 or 30 beats. In acute 
disease, a pulse rate of 150 is common, and 170 or 180 is often seen 
where other symptoms are not particularly severe. 

The rate, depth, and rhythm of respiration should be noted. The 
last often cannot be determined except by attentively watching the child 
for several minutes. In premature and very young infants a rather 
marked irregularity may be seen, often approaching the Cheyne- Stokes 
type. It is not to be taken as indicating a cerebral lesion, but seems 
rather to be due to the fact that the respiratory centre is not yet fully 
able to control the movements. Respiration of this type is seen only 
during the first weeks of life. Irregularity of rhythm at other times 
should suggest cerebral disease, usually meningitis. The respiration rate 
is proportionately greater in infants than in adults. In acute diseases 
of the lungs it not infrequently rises to 70 or 80, and occasionally it may 
be over 100 a minute. The rate is generally in proportion to the extent 
of the pulmonary lesion. 

The temperature of infants and very young children should be taken 
in the rectum, since groin or axillary temperatures are untrustworthy 
and those in the mouth difficult to obtain. Immediately after birth the 
temperature of the child is about the same as that of the mother, or a 
little higher. It falls from 1° to 3° F. in the course of the first few 
hours. Soon it again rises to 98.5° or 99° F. 



36 PECULIARITIES OF DISEASE IN CHILDREN. 

From a large number of personal observations upon healthy infants, 
1 have found that the rectal temperature under normal conditions varies 
between 98° and 99.5° F. ; occasionally the range may be as wide as 
97.5° to 100.5° F. in apparently perfect health. The heat-regulating 
centre in the brain acts only imperfectly in the young infant, and slight 
causes are enough to disturb the temperature. 

The temperature in infants is always higher than from corresponding 
causes in adults. Moreover, very high temperatures may be met with in 
eases not serious, and not infrequently when no explanation can be 
found even after thorough examination. In such cases the temperature 
seldom remains at a high point for more than a few hours. It is a 
continuous high temperature rather than a single rise which is significant 
of disease in infancy. Nothing is more perplexing to the young practi- 
tioner than the frequency with which a high temperature is seen in 
infants in cases of comparatively mild illness. 

It is common in chronic wasting diseases, in delicate infants and in 
those prematurely born, to find the temperature one or two degrees below 
the normal; 95° and 96° F. are of almost daily occurrence in hospitals, 
and much lower ones are not rare. Daily observations should be made 
with the thermometer in such conditions, just as in fever. 

Puzzling and apparently alarming temperatures are seen in infants 
as a result of the application of artificial heat. In one of my patients, 
an infant two days old, a temperature of 107° F. was caused by the 
close proximity of two large hot-water bags placed in the baby's basket. 
The younger and feebler the child the more readily are such tempera- 
tures produced. 

Muscular and Mental Development. — The general muscular develop- 
ment is determined by seeing how well the child can hold up his head, 
sit alone, stand, or walk; the mental development in young infants by 
the intelligence of expression, the manner in which they respond to 
stimuli, the recognition of objects, fright at strangers, etc. ; later in the 
first year, by the use of their hands, their understanding of speech, and 
their ability to pronounce words. 

Local Examination. — For the purpose of making a complete routine 
examination of an infant the entire clothing, with the exception of the 
napkin, should be removed, and the infant placed preferably upon the 
nurse's lap upon a blanket. With older children the clothing may be 
removed and the body examined, one part at a time, but with all children 
it is essential that the examination be complete. A warm room is indis- 
pensable, and a table covered with a blanket in many respects better 
than the nurse's lap, although the latter has usually to be employed. 
The local examination should be deliberate, the physician should pro- 
ceed cautiously, winning the child by gradual approaches, and avoiding 
excitement, force, or anything which may cause pain. 



SYMPTOMATOLOGY AND DIAGNOSIS. 37 

Shin. — The skin should first be inspected for eruptions, and it is 
important that the entire eruption be examined in order that the distri- 
bution as well as the character of the lesion may be seen. It should 
be noted also whether the skin is dry or moist. Marked wrinkling or 
loss of elasticity of the skin is one of the best indications of loss in 
weight. Bedsores are more frequently seen over the occiput than over 
the sacrum, and any large veins should be noted. 

External glands should now be examined, especially the cervical, 
axillary, inguinal, and epitrochlear. The cause of a marked enlarge- 
ment of any of these groups should be sought in the skin or mucous 
membranes with which they are connected. Marked swelling of the 
cervical glands may indicate diphtheria, scarlet fever, or a simple acute 
inflammation dependent upon a rhino-pharyngitis. Enlargement of the 
epitrochlear glands is especially significant of syphilis. General enlarge- 
ment of all the glands to a slight degree is seen in most cases of mal- 
nutrition and in many acute infectious diseases. 

Head. — One should first note whether the sutures are ossified, un- 
naturally open or separated; also whether the fontanel is closed or, if 
open, whether it is depressed or bulging. Prominences of the frontal 
or parietal regions when symmetrical are indicative of rickets. Irregular 
prominences of a smaller size, when present, are usually syphilitic. In 
the newly born, a tumour on the head, if in the median line, may indicate 
an encephalocele ; if limited to either the parietal or occipital bone it is 
usually a cephalhematoma. 

Eyes. — The condition of the conjunctiva and lids should be noted, 
also the presence of ptosis, strabismus, or other paralysis, but particularly 
the condition of the pupils, whether contracted or dilated, and the nature 
of their response to light. One should look also for the presence of 
corneal ulcers or the interstitial keratitis si frequent in late hereditary 
syphilis. 

Ears. — The presence of a discharge may be recognised by sight or 
by the odour. In any acute febrile condition one should look for tender- 
ness or swelling over the ear or mastoid. 

Nose. — The presence of any nasal discharge should be noted and its 
character determined. .An abundant discharge tinged with blood, in 
young infants, should suggest syphilis; in older children, diphtheria; a 
chronic discharge, adenoid growths; a purulent discharge of one side, 
a foreign body. 

Mouth. — The appearance of the mucous membrane of the mouth 
and gums as well as the teeth may often be ascertained by watching 
the child while he is crying. It should be noted whether the tongue is 
dry or moist, clean or coated; whether thrush is present or any other 
form of stomatitis. If the gums are congested, swollen, or hemorrhagic, 
they should suggest scurvy. The number, position, and character of 



38 PECULIARITIES OF DISEASE IX CHILDREN. 

the tooth are important. The general colour of the mucous membrane 
may be significant in eases of cyanosis in congenital cardiac disease, and 
extreme pallor of the mucous membrane in anaemia. On the mucous 

membrane of the hard palate may often be found the first local evidence 
riot fever in the form of a minute punctate eruption, and on that 
portion of the cheeks opposite the molar teeth should be sought Koplik's 
sign, the earliest reliable symptom of measles. 

Throat. — A careful examination of the pharynx and tonsils should 
never be omitted in any acute illness, no matter what other symptoms 
may be present. Not only tonsillitis, but often diphtheria, is overlooked 
from a failure to observe this as an invariable rule. A good light is 
essential, and one must train himself to take in all the appearances at 
a single glance. Marked general redness of the pharynx may be asso- 
ciated with scarlet fever, influenza, or simple acute pharyngitis. If other 
symptoms are present pointing to chronic nasal obstruction or to a 
catarrhal process of the rhino-pharynx, a digital examination should be 
made to determine the presence of adenoids. Dyspnoea with mouth- 
breathing when associated with difficulty in swallowing should, in an 
infant, always suggest retropharyngeal abscess. The examination of the 
mouth and throat may wisely be made the last step, since it usually 
disturbs a child so as to embarrass further investigation. 

Xeck. — One should consider the position in which the head is held 
and the amount of rigidity of the cervical muscles. Opisthotonus may be 
associated with meningitis or old cerebral palsy. A marked rigidity may 
indicate cervical Pott's disease or, if accompanied by torticollis, may 
be of rheumatic origin. 

Chest. — In young children particular importance should be attached 
to the shape of the chest. Symmetrical deformities are usually due to 
rickets. Contraction of one side only is most frequently the result of 
an old empyema or an extensive interstitial pneumonia. Bulging of the 
precordial region is frequent in cardiac disease. One should notice also 
the recession of the soft parts — intercostal spaces, the suprasternal notch, 
or the epigastrium; the amount of this is usually the best means of 
judging the severity of obstructive dyspnoea. Details regarding the 
physical examination of the lungs are discussed in the introductory chap- 
ter to pulmonary diseases. 

Heart. — It should be remembered that under two years old loud 
murmurs are almost invariably of congenital origin, that soft murmurs 
at the base are very frequently functional, and that acquired cardiac dis- 
ease is rare until after three years. For further details in the examina- 
tion the reader is referred to the chapters upon diseases of the heart. 

Abdomen. — There should be noted the presence or absence of tym- 
panites or abdominal tenderness, whether general or localised, and the 
existence of retraction of the abdominal walls as in meningitis. The 



SYMPTOMATOLOGY AND DIAGNOSIS. 39 

size and position of the liver and spleen are best determined by palpa- 
tion. The lower border of the liver is usually slightly below the free 
border of the ribs. If the spleen can be easily felt below the ribs, it is, 
as a rule, enlarged. If it can not be felt in a satisfactory examination, 
it is not sufficiently enlarged to be of any diagnostic importance. In 
acute disease a large spleen suggests malaria, typhoid, or tuberculosis; 
in chronic disease, malaria, syphilis, leukaemia, or anaemia. 

Spine. — The most frequent spinal curves seen in infancy are those 
due to muscular weakness. These disappear by placing the child in a 
prone position. Eachitic curvatures are of the same general character, 
but as they have usually lasted a longer time the spine is less flexible 
and the curvatures may not entirely disappear by change of posture. An 
angular deformity or even marked rigidity of the spine should suggest 
Pott's disease. 

Extremities. — The colour of the skin and the character of the periph- 
eral circulation should be noted especially in pneumonia, diphtheria, and 
other diseases attended by weakened heart. Clubbing of the fingers or 
toes may be due to congenital heart disease or to chronic disease of the 
lungs. Desquamation of the palms or soles may indicate hereditary 
syphilis or scarlet fever, even though no other evidence may be pres- 
ent. The finger-nails may give valuable information in hereditary 
syphilis. In examining the extremities one should note especially the 
presence of tenderness, flaccidity, or rigidity of muscles, whether the 
limbs are wasted or plump, and the degree of muscular power ; also any 
abnormal swelling on the shaft or near the extremities of the bones, and, 
finally, the function of the joints. A general relaxation of the liga- 
ments is common in rickets and paralytic conditions. Flabbiness of the 
muscles belongs to malnutrition and rickets; rigidity, if chronic, is 
usually indicative of cerebral palsy. Weakness of special groups, with 
atrophy and flaccid muscles, suggests poliomyelitis. Acute tenderness of 
the legs in infants should suggest scurvy. Rachitic deformities are al 
most invariably bilateral. Tuberculous bone disease affects the epiphyses, 
while syphilis usually involves the shafts, the only exception to this 
being the epiphyseal separation which may occur in the first months 
of life. 

The reflexes may be somewhat difficult to obtain in infants and when 
exaggerated may indicate cerebral palsy, meningitis, or, as in tetany, only 
an extreme irritability of the nervous centres without organic disease. 
The plantar reflex of Babinski has little significance in infants, and in 
older children it is present in many conditions. Kernig's sign is a form 
of muscular spasm almost invariably present in cerebro-spinal menin- 
gitis, but often seen in other diseases. 

Genital Organs. — Male children should be examined to determine the 
presence of phimosis or of undescended testicles. Hydrocele of the cord 



40 PECULIARITIES OF DISEASE IN CHILDREN. 

is a frequent condition, and may be mistaken for hernia. Both inguinal 
and umbilical hernia 1 are very common. In female children it should be 
remembered that preputial adhesions may be considered normal, and are 
seldom the cause of the nervous symptoms attributed to them. Every 
vaginal discharge is significant, and if purulent should be examined 
bacteriologically. The great frequency of gonococcus infections is not 
appreciated, and they may be found when least expected. 

The examination is not complete without the inspection of the stools, 
the chemical and microscopical examination of the urine, and an exam- 
ination of the blood. All are more fully considered in special chapters. 

PATHOLOGY. 

The pathological processes which result from intra-uterine disease 
and those which are connected with delivery are peculiar to early life. 
They have already been referred to in the section on etiology. Of the 
processes of early life which begin after birth, the first in frequency 
are those of the mucous membranes resulting from the various forms of 
irritation and infection. In summer, it is the stomach and intestines 
which suffer chiefly; in winter, the respiratory tract. 

The serous membranes are rarely the seat of primary inflammation. 
The pleura is seldom the seat of primary disease, but is very often in- 
volved secondarily to disease of the lung itself. Affections of the peri- 
cardium and peritonaeum are quite rare. Meningitis is fairly common, 
especially the tuberculous form. 

Diseases of the lymph nodes (lymphatic glands) play an important 
part in connection with the acute diseases of the mucous membranes, 
with many affections of the skin, and even of the viscera. Acute infec- 
tion tends to excite suppurative inflammation, particularly in infants; a 
less active process leads to chronic hyperplasia in the mesenteric, medias- 
tinal, and cervical glands, in the tonsils, adenoid tissue of the pharynx, 
etc. The lymph nodes in the neck and thorax are frequently the earliest 
seat of tuberculous deposits, and in very many cases they are the foci 
from which secondary infection of the lungs, brain, or joints may occur. 

Of the visceral inflammations x those of the lungs are the most com- 
mon, it being rare to find the lungs normal at autopsy after any acute 
infectious disease which has lasted a week. Up to the third or fourth 
year of life the heart usually escapes. In older children it may be 
involved, as in adults, in the rheumatic diseases. The liver and spleen 
are not often the seat of organic disease in early life, nor is serious disease 

1 The following table gives in a general way a very good idea of the relative fre- 
quency of diseases of the different organs in infancy. It is based upon seven hundred 
and twenty-six consecutive autopsies in the New York Infant Asylum, extending over 
a period of eight years during my connection with that institution. More than one 
half of the autopsies I made personally. Of these children seventy-two per cent were 



PATHOLOGY. 41 

of the kidney likely to be met with excepting in connection with scarlet 
fever. Organic disease of the brain itself is rare, as is also organic dis- 
ease of the spinal cord, with the exception of poliomyelitis. Chronic 

under one year, twenty-five per cent between one and two years, and only three per 
cent were over two years. The institution did not receive infants under one month, 
hence the absence of lesions peculiar to the newly born: 

Table showing principal lesions in seven hundred and twenty-six con- 
secutive autopsies in the New York Infant Asylum. 
Lungs: 

Pneumonia — Primary 139 

Complicating other acute infectious diseases 1 12 

Complicating other conditions 71 

Noted to be present in 322 

Pleurisy — No case uncomplicated with disease of lungs. 

Empyema 5 

Serous pleurisy 1 

Dry pleurisy in nearly all the severe cases of pneu- 
monia. 

Atelectasis (congenital) 6 

Pulmonary abscess (always with pneumonia) 7 

Pulmonary gangrene (always with pneumonia) ' 2 

Pulmonary tuberculosis 56 

Mouth: 

Noma 1 

Peritonaeum: 

Acute peritonitis (localised 2, with acute pneumonia and pleurisy 2) 4 
Kidneys: 

Acute nephritis (complicating scarlet fever 4, diphtheria 1, pneu- 
monia 4, measles 1, pertussis 1, ileo-colitis 2, pyonephrosis 1, 

apparently primary 5) 19 

Malformations of the kidney 7 

Stomach and Intestines: 

Acute ileo-colitis, with or without gastritis 116 

Acute gastritis (without intestinal lesions) None 

Acute diarrhceal disease (without gross lesions) 72 

Intussusception 1 

Heart: 

Pericarditis (all with acute pneumonia) 3 

Congenital malformations 3 

Acute or chronic endocarditis None 

Brain: 

Acute meningitis (7 with pneumonia, 2 cerebro-spinal) 14 

Tuberculous meningitis 11 

Acute encephalitis 1 

Chronic pachymeningitis 5 

Chronic simple meningitis 1 

Chronic hydrocephalus 3 

There were twenty-six deaths from marasmus without gross lesions. 



42 



PECULIARITIES OF DISEASE IN CHILDREN, 



diseases of the different viscera are decidedly rare, except when resulting 
from acute processes. Diseases of the bones and joints are common, and 
of extreme importance. They are usually of tuberculous, less frequently 
of syphilitic, origin. Diseases of the blood are quite common, but as 
yet but little understood. New growths are rare. The parts most fre- 
quently affected are the kidney and the bones. Disorders of nutrition 
are extremely common and of great importance, particularly rickets and 



scurvv. 



PROGNOSIS AND INFANT MORTALITY. 

The younger the patient the worse the prognosis in all the diseases of 
childhood. This is in consequence of the feeble resistance of the infan- 
tile organism to all diseases, particularly those which are of an acute 
nature. On the other hand, the rapid metabolism of childhood makes 
it possible for many conditions of an organic nature to disappear with 
time, or, as the phrase is, to be " outgrown,*' provided the patient can 
be so placed that the general nutrition can be carried to the highest 
point. 

The accompanying chart (Plate I) shows the mortality of New York 
City by months during three consecutive years, representing a total mor- 
tality of 128,136. 

The following table gives comparative figures for three periods of 
three years each, and shows the reduction in infant and child mortality 
which has taken place in the last twenty years: 

Deaths — New York City (Manhattan and Bronx). 



1890-1892. 



Under 1 year 32,916 = 26% 

1 to 2 years 10,547 = 8% 

2 " 5 " 9,794 = 7% 

5" 15 " 5,470 = 5% 

Over 15 years 69,409 =54% 

Total 128,136 



1898-19C0. 



29,326 = 24% 
9,012 = 7% 
7,292 = 6% 
6,922 = 5% 

71,024 = 58% 



123,576 



1907-1909. 



30,626 = 22.5% 

8,298 = 6.0% 

6,579 = 5.0% 

4,902 = 3.5% 

85,741 = 63.0% 



136,146 



The deaths per 1,000 of population show the same reduction. The 
curves for the different age periods are indicated in the accompanying 
chart (Fig. 6). 

The reduction in mortality in New York has been chiefly in acute 
gastro-intestinal diseases, marasmus and debility in infants over three 
months old, and acute infectious diseases, especially diphtheria. The 
mortality from certain other causes is increasing, notably, acute respi- 
ratory diseases, prematurity and diseases of the newly born. 

The only age in which the mortality is increased during the summer 



PLATE I. 



D 

D 
I 

n 


CHILDREN UNDER 1 YEAR 
M 1 TO 2 YEARS 
2 TO 5 YEARS. 
5 TO 15 YEARS 

Over 15 years. 










LI 


































































. _ 




































" - 


w?TirgTinrr^rTg?ii^TiwTT?Hiiinra 























































Chart showing by months the mortality of New York city for the different ages 
for three consecutive years. (Scale, 1 in. = 2.200 deaths.) 



PROGNOSIS AND INFANT MORTALITY. 



43 



months is the first year. In Fig. 7 are given the curves indicating for five 
years, by months, the deaths under one year and from one to five years. 





1887 1890 1893 1896 1899 1902 1905 1908 
















































2-7 






















































































2-7 














































2-4 












-v 












































V 














































\ 






























2-1 


















\ 








A 


LL 


. AG 


El 




















































21 — 














































18 




































































































































15 


























































































w 


















c^ 


/ER 


F 


V 


r 


fEA 


*S 






1-2 


























































































'», 








































9 










■ 


», 












































x 




















































», 






und-: 


R 


Fl 


vt 








Q 
























•-. 




















































l^ 7 


•• 




























S 
























% » 


3 


























{^ 










































uKic E 


R 


ONE 








.9 






































































































































Fig. 6. — Deaths — New York City per 1,000 of Population. 

The sharp rise in the summer mortality during the first year is 
chiefly due to diarrhoeal diseases. It will be noted that the curve for 
children from one to five years of age touches the highest point in the 
late winter and early spring months, the time when pneumonia and the 



DEATHS BY MONTHS, NEW YORK CITY (MANHATTAN AND BRONX.) 



d 



' s d 



ft 



V* 



r-s 



N 



tf: 



;oo 



S7 



f\ 



% 



t*<s 



I 



K 



r-* 



k' 



S 



L PPER CURVE 



UNDER ONE YEAR 



L|qWlEtRCUP[ViE^^|QNE|T|0 F.IVElYEARS 
Fig. 7. 



44 



rFATUARITIES OF DISEASE IN CHILDREN. 



common contagious diseases are most prevalent. The curve for both 
groups is lowest in the months of October and November, which may 
therefore be considered (he healthiest months in New York. The highest 
mortality is in the first month of age. During this time twenty-five per 
cent of the deaths of the first year occur. Eross, writing in 1894, states 
that from the records of sixteen large cities of Continental Europe nearly 
ten per cent of all the infants born died during the first month. These 
figures have been considerably reduced since that time. The first weeks 
of life are the period of highest mortality, because in them takes place 
the adaptation of the organism to its environment. After this period 
each month shows a steadily declining death rate to the end of the first 
year. 

Causes of Death at Different Periods. — The most frequent causes of 
infant mortality, according to the combined reports from the records of 



CHIEF CAUSES OF DEATH FIRST YEAR. 




ACUTE GASTRO INTESTINAL 28.0 PER CENT. 


MARASMUS, PREMATURITY, ETC. 25.5 » 


ACUTE RESPIRATORY 18.5 " 


CONGENITAL MALFORMATION, ETC. 5.8 •< 




ACUTE INFECTIOUS 5.4 » 




CONVULSIONS 3.4 " 




TUBERCULOSIS 2.0 << 




SYPHILIS 1.2 " 




ALL OTHERS 10.2 «< 



Fig. 8. 



the cities of New York, Philadelphia, Boston, and Chicago, making a 
total of 44,226 deaths in the first year, are shown in the accompanying 
chart (Fig. 8). 

The group, acute gastro-intestinal, includes chiefly diarrhceal dis- 
eases in summer. The acute respiratory diseases are pneumonia and 
bronchitis. Marasmus, prematurity, etc., include also congenital de- 
bility, inanition, and other conditions in which the cause of death re- 
corded is disorder of nutrition rather than some general or local disease. 
The group, congenital malformations, includes also deaths from acci- 
dents during birth. Whooping cough is the most important member of 



PROGNOSIS AND INFANT MORTALITY. 45 

the group of acute infectious diseases, diphtheria coming next. Tuber- 
culosis should, I believe, be rated higher than is shown in these figures. 
The mortality records of the Babies' Hospital show that the deaths from 
tuberculosis constitute 5.6 per cent of the first-year mortality of that 
institution. 

The figures and charts above given indicate that a very marked re- 
duction in infant and child mortality has taken place especially within 
the last twenty years. Many causes have united to ' bring about this 
result. Among those which have affected infants may be mentioned: 
A wider diffusion of knowledge of infant-feeding and hygiene; a great 
improvement in the general milk supply; the furnishing of pure, whole 
milk and of modified milk gratis, or at small cost, from milk depots; a 
general adoption during hot weather of some form of milk sterilisation ; 
the sending of a large number of infants into the country in summer; 
the closer supervision of infants in cities during the summer by visiting 
physicians and nurses, and the operation of many other agencies to im- 
prove sanitary conditions. Besides these important factors in preventing 
disease there must be considered the recent advances in paediatrics and 
the more rational treatment of the sick infant by the average physician. 

During the second year the diseases of the gastro-intestinal tract are 
still a large factor in the death rate, also the acute diseases of the lungs 
and the acute infectious diseases, especially measles, diphtheria, and per- 
tussis. Deaths from scarlet fever are much less numerous. General 
tuberculosis and tuberculous meningitis are frequent. 

From the second to the fifth year the deaths are mainly from acute 
infectious diseases — chiefly diphtheria and scarlet fever — much less fre- 
quently from measles or pertussis. In the next group come the acute 
diseases of the lungs, general tuberculosis, and tuberculous meningitis. 

From the fifth to the fifteenth year the mortality in childhood is 
remarkably small, diphtheria and scarlet fever being still in the front 
rank in point of frequency. Next come the acute diseases of the lungs, 
meningitis, diseases of the bones, appendicitis, rheumatism, and cardiac 
disease. 

By far the largest single factor in reducing mortality after the first 
year is without doubt the use of diphtheria antitoxin. The serum treat- 
ment of cerebro-spinal meningitis is important, but not influential in 
vital statistics, as cases are relatively infrequent. 

Sudden Death. — This is not a very uncommon occurrence in infants 
who are apparently healthy. They are sometimes found dead in bed 
under circumstances in which grave suspicion may unjustly rest upon 
the attendants. This usually happens with those who are delicate or 
suffering from malnutrition, especially in institutions where sudden 
death is by no means rare. The most frequent causes in infants are the 
following : 



4(> PECULIARITIES OF DISEASE IN CHILDREN. 

1. Malformations. — While in most cases malformations of a serious 
nature give rise to symptoms, they may be absent, or may be so slight 
as to be overlooked. Infants may succumb during the first few days of 
life from malformations of the heart, lungs, kidneys, stomach or in- 
testines, and sometimes from diaphragmatic or umbilical hernia. 

8. Internal Hemorrhage. — This is chiefly limited to the first two 
weeks of life. In the cases that have come to my notice the cause has 
been rupture of some subperitoneal haemorrhage into the general abdomi- 
nal cavity, or meningeal haemorrhage. Such cases are reported in the 
chapter upon Visceral Haemorrhages in the Newly Born. Under these 
circumstances no symptoms may exist until the occurrence of collapse, 
with death in a few hours. 

3. Asphyxia from Overlying. — This is not very common, excepting 
among the lower classes, and is most frequently due to intoxication on 
the part of the mother. Such t infants after death present the usual 
lesions of death from asphyxia, but without any evidence of violence. 
A recent writer in the British Medical Journal states that one thousand 
infants die every year from this cause in the city of London alone. 

4. Asphyxia from Aspiration of Food into the Larynx or Trachea. 
-^This may be due to vomiting or to the regurgitation of food during 
sleep ; in a very weak infant i + may occur while awake. This is usually 
seen in infants who are less tnan a year old, and most of the reported 
cases have been under six months. Such children are usually delicate. 
There seems to be vomiting with an attempt at crying, during which the 
food is drawn into the air passages. In some cases, as that reported by 
Demme, a single large curd of milk has been found in the larynx. In 
others, food is found in the larynx, trachea, and large bronchi. Cases 
have also been reported by Partridge and Parrot, and I have myself met 
with at least three. The infants have generally been found dead in bed 
within a few hours after feeding. This accident is more likely to happen 
when an infant lies upon his back. 

5. Enlargement of the Thymus. — Although these cases are very im- 
perfectly understood, they are not rare. I see two or three each year. 
The condition is most frequent in infancy, but is not confined to this 
period. When a child is suffering from some minor illness, often bron- 
chitis, severe attacks of asphyxia may develop and sometimes convulsions 
may unexpectedly occur and death soon follow. Or the first attack may 
not be fatal. Sometimes sudden death follows the administration of an 
anaesthetic, particularly chloroform. In most cases there is found besides an 
enlarged thymus, a general hyperplasia of the lymphatic tissues through- 
out the body known as status lymphaticus, more fully discussed elsewhere. 

6. Atelectasis. — In very young infants there may be no symptoms 
excepting malnutrition until sudden death occurs, sometimes with con- 
vulsions and sometimes without any such symptoms. (See Atelectasis.) 



PROPHYLAXIS. 47 

7. Marasmus. — In this class of cases sudden death is of very common 
occurrence. These children are often as well two or three hours before 
death as for several weeks. Death frequently occurs at night, the chil- 
dren being found dead in bed in the morning. In some of the cases the 
exciting cause seems to be the lowering of the temperature, while in 
many no exciting cause can be found; the vital spark simply goes out 
after burning for some time with- a feeble intensity. In some of these 
cases the autopsy reveals atelectasis, but in many cases nothing abnormal 
is found, death apparently resulting from heart failure. 

8. Convulsions in Children Previously Showing no Special Signs of 
Disease. — Many of these cases are seen in children who were previously 
rachitic; some arc associated with the status lymphaticus, and many are 
manifestations of tetany. The autopsy may show no lesion except cere- 
bral hyperaemia. It is extremely rare for cerebral haemorrhage to produce 
death in this way. In some rachitic cases death is due to spasm of the 
glottis. 

9. Asphyxia in Older Infants and Young Children. — This may result 
from the pressure of a retropharyngeal abscess upon the larynx or 
trachea, or from the rupture of such an abscess into the air passages. 
Previous symptoms may have been wanting. Pressure upon the pneu- 
mogastric nerve leading to fatal asphyxia may be caused by tuberculous 
bronchial nodes, or by abscesses in the .posterior mediastinum connected 
with caries of the spine. Sudden death may occur with spinal caries 
from dislocation of the upper cervical vertebrae. 

Sudden asphyxia may follow the ulceration of tuberculous lymph 
nodes and the escape of cheesy masses into the trachea or primary 
bronchi. This usually occurs in children from two to five years old. 

10. Death after a Few Hours' Illness, in which the Chief Symptom 
is High Temperature. — This is not an uncommon occurrence. Infants 
apparently well may be taken with great prostration and a high tem- 
perature, which may rise rapidly to 106° or even 107° F., and death 
follow in from six to twelve hours, sometimes preceded by convulsions. 
These are often examples of acute septicaemia, most frequently from the 
pneumococcus, sometimes from the streptococcus, or other organisms. In 
older children death may be due to malignant scarlet fever or epidemic 
meningitis; however, unless these diseases are prevailing epidemically, 
it is somewhat hazardous to make such a diagnosis. 

It does not fall within the scope of this chapter to consider cases of 
sudden death from heart failure after diphtheria, with pleurisy with 
effusion, or with myocarditis. These will be discussed elsewhere. 

PROPHYLAXIS. 

There is no more promising field in medicine than the prevention of 
disease in childhood. The majority of the ailments from which children 



48 PECULIARITIES OF DISEASE IN CHILDREN. 

die it is within the power of man in greal measure to prevent. Prophy- 
laxis should aim at the solution of two distinct problems: (1) The re- 
moval o( the causes which interfere with the proper growth and devel- 
opment of children; (2) the prevention of infection. The former can 
come only through the education first of the profession and then of the 
genera] public, in the fundamental principles of infant feeding and 
hygiene. This is a department which has received altogether too small 
a place in medical education. The latter must come through the pro- 
fession, and through legislation, the purpose of which shall be more 
rigid quarantine, more thorough disinfection, and improved sanitation 
in all its departments. The subject of prophylaxis will be discussed in 
connection with the different diseases treated elsewhere. 



THERAPEUTICS. 

Therapeutics in infancy consists in something more than a graduated 
dosage of drugs. Many therapeutic means which are valuable in adults 
are useless in children, and many others which are of little value in 
adults are extremely useful in children. Children in the past have 
suffered much from overzealous treatment, particularly from drug- 
giving. In early life more than at any other period the old dictum 
non nocire should be heeded. It should be a fundamental principle 
never to give a dose of medicine without a clear and definite indication. 
If this rule is followed, it is surprising to find how often medication 
can be dispensed with. A second rule is equally important : never to 
give a nauseous dose when one, that is palatable, will answer the purpose 
equally well. The simpler prescriptions are made, the better. As a 
rule, infants revolt against most of the highly seasoned sirups and 
elixirs which are used to disguise the taste of unpleasant doses. Bitter 
medicines when mixed with water, are frequently administered without 
difficulty. 

It is a common mistake to underestimate the importance of the 
hygienic surroundings of the patient, the value of good nursing, careful 
feeding, and judicious stimulation, just as it is to overestimate the 
beneficial effects of drugs. In the great majority of acute ailments not 
serious in character, for which a physician is called, the patient recovers 
quite as promptly without drugs as with them. This does not mean that 
such children require no treatment, but that the least important part of 
the treatment is drug-giving. In cases of severe illness, in infants 
especially, we must avoid all unnecessary medication, in order that the 
stomach may not be disturbed. Hence the importance of relying as far 
as possible upon local measures. The strong tendency to recovery from 
all acute processes, while seen in adult life, is even more striking in 
childhood, where, if we can but remove that which hampers the bodily 



THERAPEUTICS. 49 

functions, Nature will usually conduct the case to a satisfactory termi- 
nation. Thus, after an attack of bronchitis, it is often seen that the 
disturbance of the stomach and intestines can be directly traced to the 
drugs employed, and continues long after the original disease has sub- 
sided. In diseases of the stomach and intestines especially there is a 
great amount of unnecessary medication. In all chronic disturbances 
of nutrition — chronic indigestion, malnutrition, and anaemia — no tonic 
is so good as a change of air and surroundings. 

Antipyretics. — The indications for the employment of antipyretics in 
children are somewhat different from those in adults. It is to be borne 
in mind that, where the cause is similar, all temperatures in children are 
higher than in adults. Thus conditions, which in an adult would pro- 
duce a rise of temperature of only 100° or 101° F., in a child are not 
infrequently accompanied by a temperature of 104°, or even 105° F. The 
height of the temperature, as measured by the thermometer, is not to 
be taken as the only or even the best guide for the employment of anti- 
pyretics. The nervous disturbance which accompanies such a tempera- 
ture is much more important. The temperature may be 104°, or even 
105° F., and yet the child exhibit no signs of unusual discomfort. Such 
a temperature manifestly does not call for interference. High tem- 
perature from apparently trivial causes, is very common. It is only a 
continuously high temperature or a recurring high temperature which 
indicates serious illness. Whenever the temperature is found to be much 
above the normal it should be carefully watched, but not interfered with 
until a diagnosis has been made, unless the symptoms urgently demand 
it; otherwise the physician may lose one of the most valuable aids to 
diagnosis, since it is not the height of the temperature but its course 
which is significant. In many cases it is very important to know whether 
the temperature uninfluenced by drugs is remittent, intermittent, or 
steadily high, and hence the advantage of waiting until a diagnosis 
has been made before disturbing the temperature curve. This is, of 
course, not admissible when the temperature is itself a source of real 
danger, which after all is seldom the case. Since the cause of a great 
many obscure temperatures is found in the stomach and intestines, it 
very often happens that a purgative, stomach-washing, or intestinal 
irrigation may be the most efficient antipyretic. In cases of moderate 
elevation of temperature we need go no further than cold sponging. 

The most reliable antipyretic measure for children is the use of cold. 
This may be employed — 

(1) As an Ice Cap to the Head. — In many cases of quite high tem- 
perature and restlessness in infants this alone will reduce the tem- 
perature one or two degrees and allay the nervous symptoms. 

(2) Cold Sponging. — For this purpose water at about 80° to 85° F., 
equal parts of alcohol and water, or equal parts of vinegar and water may 

5 



5Q PECULIARITIES OV DISEASE IN CHILDREN. 

be employed. In the case o\' infants, all the clothing except the diaper 
should be removed and the child laid upon a blanket. The body should 
be Bponged for from ten to twenty minutes, and then wrapped in a 
blanket without further dressing. Cold sponging must be very frequently 
employed in order to be efficient in reducing high temperature. Its 
great value in allaying nervous symptoms, even when the temperature is 
not very high, is not sufficiently appreciated. Its effect is often more 
satisfactory than that of an anodyne. 

(3) Cold Pack. — This is one of the most efficient means of reducing 
temperature which can be employed. The child should be stripped and 
laid upon a blanket. The entire trunk should then be enveloped in a 
small sheet wrung from water at a temperature of 100° F. Upon the 
outside of this, ice may now be rubbed over the entire trunk, first in 
front and then behind. By this method there is no shock and no fright, 
and any ordinary temperature can usually be readily reduced. 

The rubbing with ice should be repeated in from five to thirty min- 
utes, according to circumstances, after which the child may be rolled in 
the blanket upon which he is lying without the removal of the wet pack. 
The head should be sponged with cold water while this is being carried 
on, and artificial heat, if necessary, should be applied to the feet. The 
pack is continued from one to twenty-four hours, according to circum- 
stances. 

(4) The Cold Bath. — The child is put into a bath at a temperature 
of 100° F., the temperature being gradually lowered by the addition of 
ice or cold water to 85° or 80° F. The body should be well rubbed while 
the child is in the bath and water should also be applied to the head. 
On removal from the bath, the body should be quickly dried and rolled in 
a warm blanket. The bath is usually continued from five to ten minutes. 

(5) Evaporation Baths. — The trunk is closely enveloped in two 
layers of surgeon's gauze, or some loosely woven equivalent, which is 
moistened from time to time with water at a temperature of 115° F., 
continuous evaporation being kept up by means of a hand, or better 
electric, fan. The evaporation bath would seem to possess some impor- 
tant advantages in the case of infants and young children, in that it is 
more efficient than sponging, involves little disturbance of the patient, 
and causes no shock or fright. Hot applications should constantly be 
made to the extremities. 

((>) Rectal Irrigations. — These are easily given, disturb the patient 
very little, and are effective in reducing the temperature. A double tube 
or two catheters may be employed. It is best to use at first water at a 
temperature of 90° F., and gradually reduce this to 70° F. The irriga- 
tion should be continued for ten or fifteen minutes, or even longer if the 
desired fall in temperature is not obtained, and may be repeated as often 
as every three hours. 



THERAPEUTICS. 51 

Antipyretic Drugs. — Except in cases of malaria, quinine should not 
be employed for the reduction of temperature in children. 

Of the many coal-tar derivatives employed, phenacetine has the ad- 
vantage for children of being tasteless and causing little depression, but 
the slight disadvantage of practical insolubility. None of the drugs of 
this group is, however, to be employed in large doses with the sole pur- 
pose of reducing the temperature. Their great value in paediatrics con- 
sists rather in allaying the nervous symptoms which accompany fever, 
and this purpose can be accomplished by the use of comparatively small 
doses. To an infant of one year, phenacetine or antipyrine can be given 
in one-grain doses every hour or two hours until the desired effect is 
produced. For a child of five years a dose of two grains may be given 
in the same manner. When used as indicated, these drugs are of very 
great value in making the patient more comfortable, in promoting sleep, 
and in allaying headache and general pains. In cases of hyperpyrexia 
they are, however, much less certain and less safe than the use of cold. 

Stimulants. — In spite of the many statements to the contrary, alco- 
holic stimulants are well tolerated even by very young infants. All 
stimulants, and alcohol in particular, are very greatly abused in the 
hands of practitioners, and their indiscriminate and protracted use can 
not be too strongly condemned. 

The iudications for the employment of stimulants are much the same 
in young children as in adults. In most of the acute fevers they are 
not to be given early in the disease, and in many cases they are not re- 
quired at all. They must often be used very sparingly while the tem- 
perature is high, but may be necessary as soon as it falls. In many acute 
febrile diseases stimulants are not called for at any period. 

The method of administering alcohol is of no little importance. 
Brandy and whisky are in most cases to be preferred to the wines, but 
not always. For infants under one year old, brandy should be diluted 
with at least eight parts of water. Altogether the best method of admin- 
istration is to determine the amount to be given in every twenty-four 
hours, have it diluted sufficiently, and then administer it in small doses 
at short intervals. 

An infant one year old, for whom alcohol is indicated, should not be 
given to begin with more than one-fourth of an ounce of brandy or whisky 
during the twenty-four hours, and even in bad conditions it is rarely 
advisable to give more than twice this quantity, except for a very short 
period. In children four years old double the amount may be employed 
in the corresponding conditions. Little good and much harm is likely 
to follow such amounts as six or eight ounces daily of brandy or whisky 
for children of two or three years. There certainly is a strong tendency 
at the present time to use less and less alcohol in therapeutics, and many 
would abandon it altogether. 



52 



PECULIARITIES OF DISEASE IN CHILDREN. 



Other stimulants, caffeine, camphor, strychnine, digitalis, stro- 
phanthus, etc., arc used in children with much the same indications as 
in adults. Their application is more fully discussed in the different 
ses in which they arc employed. They may be used in the follow- 
ing doses at the different ages indicated: 



"Digitalis, tincture 

Strophanthus, tincture 

Caffeine citrated 

Strychnine sulphate 

Camphor (10 per cent solution in oil). 
Adrenalin (1-1000 Sol.) 



3 months. 


1 year. 


5 years. 


TTL i 


IT), iii 


HI V 


m 


TTL ii 


HI V 


Gr. i 


Gr. | 


Gr. i 


Gr. t^o 


Gr. 2vs 


Gr.eV 


1TI iii 


Tf|. vi 


TO. x 


1U 


ITt iii 


TTl vi 



Note. — Camphor and adrenalin are for hypodermic use only. The dosage of all 
these stimulants is calculated for administration at intervals of four hours. 

Tonics. — Cod-liver oil is particularly useful in the convalescence 
after acute diseases of the respiratory tract, in anaemia, and in a large 
number of children who are extremely delicate. In these patients it 
may be advantageously administered throughout the greater part of 
nearly every winter season. In convalescence after attacks of gastro- 
enteric disease it should be withheld for a long time. When the tongue 
is coated, the digestion poor, and the stomach easily disturbed it should 
not be given at all. In the case of infants, as a rule, the pure oil is to 
be preferred to the emulsion. The administration of small doses — i. e., 
ten or twenty drops of the oil three times a day continued for a long 
period — is much better than the use of larger doses for a shorter time. 

Preparations of malt are sometimes of even greater value than cod- 
liver oil, for they can be used in many conditions when the oil is contra- 
indicated.. The two may often be advantageously combined. The best 
preparations of iron for very young children are the bitter wine, sweet 
wine, saccharated carbonate, and the wine of the citrate. These are only 
slightly constipating, and many of them can be given with milk. Most 
of the organic preparations of the market are less reliable than those 
mentioned. For older children nothing is better than reduced iron or 
Blaud's pills. 

Arsenic is second only to iron in the treatment of the anaemia of chil- 
dren, and in very many cases it is to be preferred to iron. The tablet 
triturates of arsenious acid, one one-hundredth of a grain, may be given 
immediately after meals three times a day, or one or two drops of 
Fowler's solution largely diluted with water. 

Alcohol is useful in combination with some of the bitters, either 
small doses of quinine, mix vomica, or the bitter wine of iron. I T sually 
wines, especially sherry, are to be preferred to spirits, although some 
children take spirits better. When combined with a bitter there is little 



THERAPEUTICS. 



53 



danger of the formation of the alcoholic habit, even though its use may 
be long continued. 

Of the bitter tonics, mix vomica is easily superior to all others. 

Opiates. — Strong objections have been urged by many against the 
employment of opium in the diseases of infancy. While opiates have 
no doubt been abused, the fact remains that opium is almost as valu- 
able a remedy in the treatment of disease during the first five years 
as at any other period of life. For infants relatively smaller doses 
are required than of most drugs. If the physician will accustom him- 
self to the use of very small doses, he will be surprised to see how satis- 
factory are the effects produced. 

The most useful preparations for young children are paregoric, 
Dover's powder, the deodorised tincture, morphine, and codeine. The 
following table gives what may be considered safe initial doses at the 
different ages: 



Paregoric 

Deodorised tincture 
Dover's powder 

Morphine 

Codeine 



1 month. 



Hi 

Or. -A- 
Gr. -nfoTT 
Gr. 3 iVtt 



3 months. 



HI ii 

Gr. A 

Gr. W.tt 
Gr. t^ 



HI v to x 



Gr. 
Gr. 
Gr. 



to 



5 years. 



TT1_ xxx to xl 

Tfl ii to iii 
Gr. ii to iii 
Gr. -3-Vt to Jjt 
Gr. -h to i 



Ordinarily doses like the above should not be repeated oftener than 
every two hours. In exceptional circumstances, as when very great pain 
is present, the dose may be given more frequently. In the hypodermic 
use of morphine it should be remembered that its effects are always more 
uniform and striking than when the drug is administered by the mouth, 
and the dose should therefore be smaller. In every instance where a full 
dose of opium has been given the physician should wait until the effects 
have subsided before the dose is repeated. 

Sedatives. — For most of the milder conditions where sedatives are 
required bromides are to be preferred. A preference should be given to 
the sodium salt. Young children require relatively large doses: e. g., in 
convulsive conditions three grains every two hours are often necessary 
at three months. Chloral is usually well borne even by quite young 
infants. Since it is often irritating to the stomach it may be advan- 
tageously given by the rectum. After rectal administration its effects 
are usually manifest in half an hour, and sometimes sooner. The rectal 
dose for an infant of one month is one grain ; three months, two grains ; 
one year, three to five grains. It may be repeated every two to four 
hours, according to indications. Doses by mouth should be about half 
as large. Other drugs may replace this in most diseases, but in the case 
of infantile convulsions nothing is so reliable as chloral. 



54 PECULIARITIES OV DISEASE IN CHILDREN. 

Belladonna is well borne by children, and in relatively Larger doses 
than most drugs. A tolerance is quite readily established. The eruption 
is more readily produced than the other physiological effects, and even 
quite small doses may be sufficient to bring out a very abundant blush. 
The parents should be advised of this fact, Lest undue alarm be felt. 

The drugs classed as antipyretics — phenacetine and antipyrine — are 
exceedingly valuable in the treatment of many diseases of infancy where 
irritative nervous symptoms are prominent. In many cases they may 
advantageously take the place of opium, except where pain is the prin- 
cipal symptom, as in otitis or pleurisy. In all conditions where spasm 
is a prominent symptom, whether of the larynx or bronchi, or local 
or general convulsions, antipyrine is especially valuable. 

Drugs Well Borne hy Children. — In this list might be mentioned 
belladonna, the bromides, the iodides, chloral, quinine, calomel — in fact, 
all mercurials — and alcohol. 

The drugs not well borne include particularly cocaine and heroin. 
In the case of many others, while the constitutional effects are well tol- 
erated, they must be given carefully to young infants, since they are 
irritants to the stomach. In this class may be mentioned the salicylates, 
salol, the astringent preparations of iron, and the acids. 

Vaccines. — These are suspensions of dead bacteria in a normal salt 
solution. Their application in paediatrics is confined to therapeutics; 
as a prophylactic measure they are seldom called for. Vaccine therapy 
has been employed in almost every form of bacterial infection. In the 
great majority of these the results have been disappointing. They are 
of unquestioned value in localised staphylococcus infections, particularly 
those of the skin, e. g., general furunculosis and larger multiple ab- 
scesses. In other staphylococcus infections the}' are sometimes useful, 
but results are very uncertain. In streptococcus infections whether 
localised or general their effect is doubtful; although in rare cases they 
have seemed to be of benefit. Pneumococcus infections are apparently 
not at all influenced by their use. Regarding the effect of vaccines on 
gonococeus infections of mucous membranes, one must speak very guard- 
edly. The great majority of patients with gonococcus vaginitis so treated 
have received but temporary benefit, although a few striking cures have 
been obtained. Colon infections of the urinary tract (pyelitis) some- 
times appear to be decidedly improved by vaccines. With respect to most 
other conditions experience thus far does not warrant one in forming a 
sanguine opinion of their value. For the technique of vaccine treatment 
special works should be consulted. 

Counter-irritants. — These are of great value in a large variety of 
disea 

The mustard paste is probably the most satisfactory means of pro- 
ducing quick counter-irritation over a large surface. To make a mustard 



THERAPEUTICS. 55 

paste : Take one part powdered mustard and six parts of wheat flour, mix 
with lukewarm water, and spread between two layers of muslin. This 
should be removed as soon as a thorough redness of the skin has been 
produced — in most cases from five to eight minutes, according to the 
strength of the mustard employed. This may be repeated as often as 
every three hours, and continued for a week if necessary, without pro- 
ducing excoriations of the skin. For older children the paste may 
be made one part mustard to four parts flour. In pulmonary diseases 
it should be large enough to surround the chest. When it is used 
to produce general reaction in heart failure it should cover the entire 
trunk. 

The Mustard Pack. — The child is stripped and laid upon a blanket, 
and the trunk is surrounded by a large towel or sheet saturated with 
mustard water. This is made as follows : One tablespoonf ul of mustard 
to one quart of tepid water. In this a towel is dipped, and while drip- 
ping wound around the entire body. The patient should then be rolled 
in the blanket. This pack may be continued for ten or fifteen minutes, 
at the end of which time there will usually be a very decided redness of 
the whole body. It may be repeated according to indications. Where it 
is desired to produce a general counter-irritation, the mustard pack is not 
quite as efficient as the mustard bath, but it has the advantage in causing 
much less disturbance to the patient. The mustard pack is useful in the 
condition of collapse or of great prostration from any cause whatever, in 
convulsions, and in cerebral or pulmonary congestion. 

The turpentine stupe is made by wringing a piece of flannel out of 
water as hot as can be borne hy the hand. Upon this is sprinkled ten or 
fifteen drops of the spirits of turpentine. The stupe is then applied to 
the body and covered with oiled silk or dry flannel. It is useful chiefly 
in abdominal pains or inflammations, but in infancy must be carefully 
watched or vesication will be produced. For continuous use it is not so 
valuable as the mustard paste. 

Stimulating liniments containing turpentine and other irritants are 
useful in inflammations of the chest, although less reliable than the mus- 
tard paste. One of the mildest and most useful preparations is camphor- 
ated oil. Another is olive oil four parts and turpentine one part. These 
may either be rubbed upon the surface, or a piece of flannel may be satu- 
rated with them and then applied to the skin. 

Local Blood-letting. — Leeches are sometimes useful in the early 
stages of acute inflammations of the mastoid or middle ear. They may 
also be applied to the praecordium in acute pneumonia with signs of fail- 
ure of the right heart, viz., great dyspnoea and cyanosis. 

Dry cups may be used even in young infants, to relieve acute conges- 
tion in pneumonia or bronchitis, and for pulmonary oedema. Wet cups 
should never be used for young children. 



56 PECULIARITIES OV DISEASE IN CHILDREN. 

Poultices are much too frequently employed and may with advantage 
be omitted in the treatment of most local inflammations. They have 
1 een largely replaced by wet dressings, especially those of aluminum 
acetate. In acute pulmonary inflammations their use is very limited. 

Cold. — Cold is useful in almost all forms of local inflammation. In 
inflammation of the cervical lymph glands and of the joints it is of 
undoubted value, but its advantage over heat is questionable. The effi- 
ciency of both cold and heat in these cases depends largely upon the 
method of use. The difficulties in the way of their proper application 
are great in young children. Sometimes in pleurisy much greater relief 
is obtained from the use of an ice bag to the chest than from hot appli- 
cationSj but this is not the general experience. The treatment of 
pneumonia by the application of the ice bag to the chest has many advo- 
cates, although in my own hands it has not yielded the results claimed 
for it. It is admissible only in lobar pneumonia, and here chiefly in older 
and stronger children. The application of cold in young or very deli- 
cate children should be made with caution in all inflammations of the 
respiratory tract. 

Cold is best applied to the head by an ice cap made like a helmet ; an 
ordinary rubber or flannel bag filled with ice may answer the purpose. 
The rubber coil filled with ice water is also an excellent method. For 
inflamed glands or joints the ice bag or the coil should be used; for the 
eyes , cold compresses, changed every minute. 

The Hot Pack. — All clothing is to be removed and the child's body 
covered with towels wrung from water at a temperature of from 100° to 
108° F., after which the body should be rolled in a thick blanket. These 
hot applications may be changed every twenty or thirty minutes until free 
perspiration is produced, which may be continued as long as necessary. 
This is mainly useful in uraemia. 

The hot bath, like the mustard pack or the mustard bath, may be 
used to promote reaction in cases of shock or collapse. The patient should 
be put into the bath at a temperature of 100° F., the water being gradu- 
ally raised to 103°, or even to 106°, but rarely above this point. The body 
should be well rubbed while the patient is in the bath. A thermometer 
should be kept in the water to see that the temperature does not go too 
high. L^nless this precaution is taken the danger of burning the child is 
great. During the bath, in most cases, cold should be applied to the 
head. 

The Hot-Air or Vapour Bath. — All the clothing should be removed 
and the patient laid upon the bed with the bedclothing raised above the 
body ten or twelve inches, and sustained by means of a wicker support. 
The bedclothing should be pinned tightly about the neck, so that only 
the head is outside. Beneath the bedclothing hot vapour is introduced 
from a croup kettle or a vapouriser. This will usually induce free per- 



THERAPEUTICS. 57 

spiration in fifteen or twenty minutes. It may be continued from twenty 
to thirty minutes at a time. Instead of vapour, hot air may be intro- 
duced in the same way. The air space about the body is indispensable. 
The vapour bath is applicable chiefly to cases of uraemia. 

The Mustard Bath. — Four or five tablespoonfuls of powdered mustard 
should be mixed for a few minutes with one gallon of tepid water. To 
this should be added four or five gallons of plain water at a temperature 
of 100° F. The temperature of the bath may be raised by the addition of 
hot water to 103° or 106° F., if desired. Nothing is more efficient than 
the hot mustard bath for a general derivative effect in bringing the blood 
to the surface in cases of shock, collapse, heart failure from any cause, or 
in sudden congestion of the lungs or brain. The bath should not usually 
be continued for more than ten minutes. If necessary, it may be re- 
peated in an hour. 

The Bran Bath. — Put one quart of ordinary wheat bran in a bag made 
of coarse muslin or cheese cloth and place this in four or five gallons of 
water. The bran bag should be frequently squeezed and moved about 
until the bath water resembles a thin porridge. It may be of any tem- 
perature desired, but usually about 90° to 95° F. is best. A bran bath is 
of great value in cases of eczema, excoriations about the buttocks, or in 
other cases where the skin is very delicate, and plain water seems to irri- 
tate it. 

The tepid bath may be given at a temperature of 95° to 100° F. It 
is very useful in many conditions of excitement or extreme nervous 
irritability. To induce sleep it is often more efficient than drugs. 

The cold sponge or the shower bath should be given in the morning 
before breakfast, and in a warm room. The child should stand in a 
foot tub containing warm water enough to cover the feet, then a large 
sponge holding about a pint of water at a temperature of from 40° to 60° 
F. should be squeezed three or four times over the chest, shoulders, and 
spine of the child, the skin being rubbed meanwhile. The bath should 
not last more than half a minute. It should be followed by a brisk rub- 
bing until a thorough reaction is established. This is very useful at all 
ages, but it is a particularly valuable tonic in delicate children. It may 
be used in those only eighteen months old. Not the least of the bene- 
ficial results is the full expansion of the lungs from the strong cry 
which the bath usually excites. In younger infants a cold plunge may be 
substituted. This should be merely a single dip of the entire body in 
water at a temperature of 50° to 60° F. In order that beneficial effects 
shall follow the cold plunge or cold sponging, a good reaction must 
be established. If children lack sufficient vitality to secure this, and 
if they remain pale, pinched, and blue for some time after the bath, 
it must be discontinued altogether, or water of a higher temperature 
used. 



;,S PECULIARITIES OF DISEASE IN CHILDREN. 

Nasal Spray. — This may be either of an aqueous or oily solution. For 
the oil spray an atomiser should he employed. It is valuable in cases 
of dry catarrh, where there is a formation of crusts in the nose. A 
variety of oils may be used, benzoinol being perhaps as satisfactory 
a< any. 

There are many forms of hand atomisers to be found in the market 
for the production of aqueous or oil sprays. For a cleansing nasal spray, 
DobelTs solution, Seller's solution, or a two-per-cent solution of boric 
acid may be used. 

Nasal Irrigation. — In cases of considerable nasal obstruction and in 
the more serious affections of the rhino-pharynx, only the syringe can be 
considered an efficient means of cleansing the cavity. 

The fountain syringe has the advantage of being easily regulated 
as to the force employed, this being determined by the height at which 
the bag is suspended above the bed. For ordinary purposes an eleva- 
tion of one or two feet is sufficient, and rarely is a greater pressure 
than three feet advisable. The last is desirable when a thorough flushing 




Fig. 9. — Nasal Syringe. 

of the rhino-pharynx is required. The position of the patient is the 
same as that shown in Fig. 10. The danger of forcing fluid into the 
middle ear is greatly lessened if the patient keeps the mouth wide 
open. 

Where a smaller amount of fluid is sufficient a piston syringe may 
be employed. This should be small enough to be easily worked with 
one hand. It should have a soft rubber tip, to prevent injuring the 
nasal mucous membrane, and the tip should be large enough to fill the 
nostril. The best piston syringe for nasal use is shown in Fig. 9. This 
is made either of glass or hard rubber, and fulfils all the conditions 
mentioned. It is easy of action, can be readily cleansed, and holds 
about half an ounce. The same syringe should not be used for more 
than one patient, unless it has been very thoroughly disinfected. In hos- 
pitals, and even in private practice, nasal syringes are frequent carriers 
of infection. 

Either of two positions may be used in nasal syringing. In diph- 
theria, scarlet fever, or any constitutional disease attended by great de- 
pression, the child should not be removed from the bed. The syringing 
may be done by a single nurse, who stands at the head of the bed, alter- 
nately syringing the right and left nostril, turning the head from side 



THERAPEUTICS. 



59 



to side (see Fig. 10). The other method is to hold the child erect 
on the lap, with the head inclined somewhat forward, the syringing 
being done by a second person standing behind. In either position the 
child's arms and hands should be securely pinioned to the sides by 




Fig. 10. — Method of Syringing the Nose. 



a sheet. To make sure that the rhino-pharynx has been reached the 
water should return through the opposite nostril or the mouth. When 
properly done, no prostration and very little irritation are caused. The 
bulb (Davison) syringe should not be employed for nasal irrigation; as 
the pressure can not be satisfactorily regulated, fluids are likely to be 
forced into the Eustachian tubes. 

Syringing the mouth and pharynx is useful in many pathological 
conditions of these parts, particularly in children too young to gargle. 
Either the fountain, piston, or bulb syringe may be used. If the pharynx 
is to be reached, the nozzle is used as a tongue depressor. This should 
be placed at the angle of the mouth between the back teeth. The child 
should lie upon the side or be held in the sitting posture, with the head 
inclined forward. Only bland solutions should be employed. 

Inhalations. — These are of very great utility in all affections of the 
respiratory tract. To be efficient, the patient should be put under a 
tent. A satisfactory tent may be made by erecting a T-shaped piece of 
wood at the head and foot of the crib and throwing over this a large 
sheet folded and pinned at the corners. Another method is, to stretch 
a cord around the top of each of the four posts of the crib, or simply 
from the centre of the head piece to the centre of the foot piece : the sheet 



GO 



PECULIARITIES OF DISEASE IN CHILDREN. 



should be used as in the first instance. A very good tent may be im- 
provised by throwing- a large shoot over an open umbrella. Instead of 
an ordinary cotton sheet one of rubber cloth may be used. For hospital 
use 1 have found it convenient to have a rubber cover made to fit closely 
over the top o( the crib to he used for inhalations. The better the tent 
the more satisfactory are the results from inhalations. 

Inhalations may be in the form of vapour or spray. The apparatus 
employed may he the croup kettle, the vapouriser, or the steam atomiser. 
As all of these are used with alcohol lamps, innumerable accidents from 
fire have occurred with them. Patients and nurses should always be 
cautioned regarding this. Whenever possible, the electric heater should 
be substituted. The ordinary croup kettle is a clumsy affair and es- 
pecially likely to be the cause of accidents. In Fig. 11 is shown one 
of an improved pattern, 1 which possesses the advantages both of the ordi- 
nary croup kettle and of the 
vapouriser. The base has been 
weighted, to prevent the ap- 
paratus being easily upset. The 
pail is low, which fact also con- 
tributes to its stability. It is 
provided with a safety alcohol lamp, the 
flame of which can be regulated by a screw. 
The lamp holds enough alcohol to burn 
from five to six hours. This kettle may be 
used to produce simple vapour, or vapour 
from lime water, or a medicated vapour 
may be employed. If the latter is de- 
sired, the substance to be vapourised is 
placed on a sponge held in the expansion 
of the spout. The kettle should be filled 
with hot water before using. It should be 
placed upon the floor or a low box beside 
the crib, standing in a large tin basin to 
avoid accident, at such a height that the end of the spout is just inside 
the tent at a level with the surface of the bed. 

There are various other forms of apparatus for the purpose of ob- 
taining medicated inhalations. 

Stomach-washing consists in the introduction of water into the stom- 
ach through a flexible catheter or stomach tube and then siphoning it 
out. It was introduced into general practice among infants by Epstein, 
of Prague. It is one of the most valuable therapeutic measures we pos- 
sess. The procedure is very simple, and may be considered entirely free 




Fig 



11. — The Author's Croup 
Kettle. 



Made by Lewis & Conger, 130 W. 42d St., New York. 



THERAPEUTICS. 61 



A 




from danger ; in fact, it is difficult to pass the tube anywhere else than 
into the oesophagus. The amount of prostration produced by stomach 
washing may be compared to that of an ordinary attack 
of vomiting. 

The apparatus for stomach-washing (Fig. 12) con- 
sists of a soft-rubber catheter, size 16, American scale (24 
French) — one with a large eye is preferred; a glass 
funnel, holding four to six ounces; two feet of rubber 
tubing, and a few inches of glass tubing to join this 
to the catheter. The child should be held in a sitting 
or recumbent posture (Fig. 13), the body well protected 
by a rubber sheet, with a large basin 
conveniently near. The catheter should 
be moistened. While the tongue is de- 
pressed with the forefinger of the left 
hand, the catheter is passed rapidly back 
into the pharynx and down the oesoph- 
agus. It is important that the first 
part of the introduction should be as 
rapid as possible, for if the child begins 
to gag from the pharyngeal irritation the 
introduction of the "tube may be quite Fig. 12. -Apparatus for Stomach- 

J l WASHING. 

difficult. K"o resistance is ordinarily en- 
countered after the tube reaches the oesophagus. About ten inches of 
the catheter should be passed beyond the lips. When it has reached the 
stomach the funnel should be raised as high as possible, to allow the 
escape of gases almost invariably present. It should then be lowered, in 
order to siphon out the fluid contents. If nothing escapes, the funnel 
is then to be raised and from two to six ounces of water poured into it 
from a pitcher; the funnel is then lowered and the water siphoned out. 
This procedure is repeated from four to ten times, or until the fluid 
comes back clear. About a quart of water is ordinarily used. Various 
solutions have been advised for stomach-washing, but nothing is better 
than boiled water, used at the temperature of from 100° to 110° F. — the 
higher temperature being employed when the gastric irritation is very 
great. If much tenacious mucus is present in the stomach an alkaline 
solution (bicarbonate of soda, oj to Oj) is preferable. Through the tube 
are easily discharged mucus and small curds; larger ones are gradually 
broken down by repeated washing. Vomiting may be induced by over- 
distending the stomach with water. If. there is great thirst there is often 
an advantage in leaving one or two ounces of water in the stomach. To 
this water it is at times beneficial to add lime water. 

Stomach-washing in its application is practically limited to children 
under two and a half years. It is easiest in those under eighteen months. 



62 



PECULIARITIES OV DISEASE IN CH1LDKKN. 



Children of three years and over are usually so much alarmed and strug- 
gle so violently as to make it difficult and undesirable. 

The indications for stomach-washing are: (1) Acute gastric indiges- 
tion, either with or without persistent vomiting. Here the purpose is 




k. 



Fig. 13. — Position for Stomach-washing. 

simply to clear the stomach of its irritating contents, and a single wash- 
ing may be sufficient. (2) Chronic indigestion attended by the pro- 
duction of gastric mucus. (3) Dilatation of the stomach. (4) Hyper- 
trophic stenosis of the pylorus. (5) Poisoning. 

Gavage.— Gavage consists in the introduction of food into the 
stomach by a tube passed through the mouth. The same apparatus is 
employed as in stomach- washing, and the method is similar, with the 
exception that for gavage the child should be placed upon the back, the 
head being steadied by an assistant. With older children a mouth-gag 



THERAPEUTICS. 63 

is often necessary. After the tube has entered the stomach the funnel 
should be raised to allow the gas to escape. The food is then poured 
into the funnel ; as soon as it has disappeared the tube is tightly pinched 
and quickly withdrawn, to prevent food from trickling into the pharynx, 
since this is often a cause of vomiting. If the food is regurgitated this 
usually happens at once. It may then be introduced a second time. 
After feeding, the child should be kept absolutely quiet upon the back. 

In cases where all the food is given by gavage the interval between 
feedings must be considerably longer than under other circumstances. 
Often the food given should be partially predigested, since digestion in 
these cases is usually feeble. The stomach should be washed before each 
feeding, in order to remove mucus and to be sure that it is empty be- 
fore the meal is given. 

Gavage is valuable in the feeding of premature infants and after 
certain operations upon the mouth and neck. It is also useful, first, in 
the case of very young infants, who, suffering from severe malnutrition, 
can not be induced to take food enough to sustain life; secondly, in 
many acute diseases, particularly in septic cases where the child will 
not readily take the necessary food, as in diphtheria, scarlet fever, 
typhoid, pneumonia, etc. ; thirdly, in many cases of cerebral disease 
where food is refused on account of delirium or coma; and, fourthly, 
in some cases of persistent vomiting, as first suggested by Kerley. 

Gavage is a very simple procedure and one which a nurse can easily 
be taught. Not only may food be given, but also medicines and stimu- 
lants as may be required, with little or no trouble. The advantage of 
gavage over the continued coaxing or holding the nose and forcing the 
patient to swallow, will be at once apparent to one using it. 

Nasal Feeding. — The method is similar to gavage, the only difference 
being that the tube is passed through the nose, and consequently a much 
smaller one is used. No. 10 American or No. 16 French scale is a proper 
size. Nasal feeding is applicable to children over two years old, in whom 
the tube can seldom be passed through the mouth without the use of a 
gag, and then only after much struggling. It is of value after intuba- 
tion, tracheotomy, and other operations about the throat, also in some 
cases of throat paralysis, especially after diphtheria. 

Irrigation of the Colon. — By irrigation of the colon is meant the 
flushing of the entire large intestine by fluids injected high up through 
a catheter or rectal tube. 

The apparatus required for irrigating the colon is a fountain syringe, 
five or six feet of rubber tubing, and a flexible rectal tube or soft-rubber 
catheter — No. 26 or 27, French scale, being preferred. Kemp's double- 
current tube of hard or flexible rubber is useful. The same result can 
be obtained by using two catheters, the larger for outflow, the smaller 
for inflow. The child is placed upon the back, with the thighs flexed 



Ii4 



PECULIARITIES OF DISEASE IN CHILDREN. 



and the buttocks brought to the edge of the bod or table. He should lie 
upon a Kelly pad or a rubber sheet so arranged as to form a trough 
emptying into a largo basin or tub. The bag containing the water is 
hung two or three feel above the bed. If a catheter is used it is inserted 
just within the Bphincter before the water is turned on. As it flows 




Fig. 14. — Colon of a Child Six Months Old, in Position. (From a photograph.) 

the catheter is gradually pushed upward to a distance of twelve or four- 
teen inches. The water distending the intestine in advance of the cathe- 
ter usually makes its introduction quite easy. In Fig. 14 is shown the 
colon of an infant of six months in position. It is the peculiar curve 
and the great length of the sigmoid flexure that make the introduction 
of water difficult, unless the tube is inserted for some distance. 

Usually a pint, and often a quart, will be introduced before any water 
returns. At least a gallon of water should be used for a single irrigation. 
The washing should be continued until the water returns quite clean. 
Change of posture and gentle kneading of the abdomen should be em- 
ployed during the irrigation, particularly the early part of it, to facili- 
tate the introduction of the water into the upper part of the colon. At 
the end of the irrigation the rubber tube is detached and the water al- 



THERAPEUTICS. 65 

lowed to escape through the catheter, which remains in situ. Sometimes 
as much as a pint of water remains in the intestine. This is usually 
passed within half an hour. As the irrigation of the colon almost in- 
variably excites active peristalsis of the lower ileum, this part of the 
intestine is emptied as well. It is to be remembered that the colon of an 
infant six months old will hold about one pint without distention, and 
at the age of two years from two to three pints. 

Irrigation of the colon is useful to clear this part of the intestine of 
mucus, faecal matter, undigested food, and the products of decomposi- 
tion. It may also be employed as a means of local medication in ileo- 
colitis. Where the object is simply to cleanse the intestine, a saline 
solution — a teaspoonful of common salt to a pint of water — is pre- 
ferred. 

The temperature of the water used for irrigation may be varied 
according to the special indications. For ordinary purposes, where 
cleansing only is aimed at, a temperature of from 95° to 100° F. seems to 
be best. When the body temperature is high, or when there is much 
pain, tenesmus and straining, cold water has important advantages. 

Irrigation under most circumstances is required only once in twenty- 
four hours. It is important to use a large quantity of water. It must 
be done thorough^ to be of value, nnd either by the physician himself 
or an experienced nurse. 

In collapse or great prostration hot saline injections may be em- 
ployed for purposes of stimulation; the temperature of these should be 
from 105° to 110° F. 

Enemata.— Simple enemata are useful in infants and older children 
for constipation. Where an immediate effect is desired the most efficient 
is one containing glycerine — e. g., for an infant, one teaspoonful to one 
ounce of water. Oil enemata (one half to one ounce) are useful where 
the faecal mass is hard and dry and expelled with difficulty. Enemata 
should always be given with care, and preferably a rubber catheter should 
be attached to the nozzle of the syringe. 

Xutrient enemata have a limited application in infancy, as the rec- 
tum soon becomes intolerant. The quantity injected should be small, 
rarely more than one or two ounces, and the interval between injections 
should be at least four hours. In older children they may be used as in 
adults. For this purpose either completely peptonised milk or glucose 
may be employed. 

The administration of drugs 'per rectum is useful in certain cases 
where, on account of the unpleasant taste or vomiting, the administration 
by mouth is difficult — e. g., quinine and chloral. As a diluent, gruel is 
preferable to water. If quinine is used, the bisulphate is the best prepa- 
ration, but this must be well diluted. The temperature of enemata which 
are to be retained should be about 100° F. It is necessary in infancy to 
G 



56 PECULIARITIES OV DISEASE IN CHILDREN. 

the buttocks together for half an hour afterward to prevent the 
expulsion o\' the injection. 

Hypodermic Medication. — This is not so often used in young children 
as it should be, and is o( the greatest service even in infancy. The use 
of morphine hvpodenuieallv in convulsions, of morphine and atropine 
in cholera infantum, o\' Btrychnine, adrenalin, caffeine, or digitalis in 
heart failure, may be cited as examples. 

Hypodermoclysis. — This is a therapeutic measure of considerable 
value in a few conditions, chiefly when the system is suffering from a 
rapid loss of fluid as in some forms of acute diarrhoea, less frequently 
after severe haemorrhage from whatever cause. A sterile normal salt 
solution is employed at body temperature and may be injected into 
any of the areolar planes of the body. With young infants the prefer- 
able location is between the scapulae; next, the abdomen or the lateral 
thoracic region. For very small patients injections should be made at 
several points. The amount injected at one time may vary from one 
to four ounces for an infant, and from four to sixteen ounces for an 
older child. The apparatus should be carefully sterilised. One may 
employ a piston syringe with a connecting rubber tube and a hypodermic 
or fine exploring needle, or a funnel may be substituted for the syringe. 

Massage. — In older children massage is useful for the same condi- 
tions as those for which it is employed in adults; the most important 
are anaemia, general malnutrition, chorea, and chronic constipation. It 
is necessary that in the beginning only the mildest movements of massage 
should be employed, and these but for a short time. 

In infancy massage has a limited application, and it is doubtful 
whether it really does more than can be accomplished by the general 
friction of the body. This rubbing, either with the bare hand or with 
cocoa butter, or with some form of fat, is useful in malnutrition, in 
rickets, and in wasting diseases where the circulation is feeble and the 
muscular tone low. Cocoa butter is cleanly and has a pleasant odour, and 
is, I think, quite as valuable as the more commonly employed cod-liver 
oil, which is exceedingly disagreeable. The inunctions should be given 
daily after the morning bath, before an open fire. The rubbing should 
be continued for fifteen to twenty minutes. 

Anaesthetics. — As a general anaesthetic for routine use, ether is to be 
recommended for children. Its disadvantages can largely be overcome 
by proper administration ; in point of safety it is immeasurably superior 
to chloroform for the very young. The administration of ether to young 
children may be advantageously preceded by a few whiffs of nitrous 
oxide or ethyl chloride; both, however, are to be used with caution in 
infants. Ether should be given slowly, well diluted with air, and if used 
in this way its unpleasant features may be obviated. This can best be 
accomplished by the use of some special form of inhaler. Ether should 



THERAPEUTICS. 67 

not be selected as the anaesthetic for patients suffering from nephritis, 
bronchitis, pneumonia, pleurisy, or any other disease attended by ob- 
structed respiration. For all these conditions chloroform is much safer. 

The dangers from chloroform are greatest when it is given too 
rapidly or in too concentrated a form. Both are exceedingly likely to 
occur where it is administered to a struggling child. The greatest care 
and judgment should be exercised at such times, or disastrous con- 
sequences may follow. To produce and maintain the effect desired with 
the minimum amount of chloroform should always be the aim. All 
anaesthetics, but especially chloroform, are dangerous in children with 
the so-called lymphatic diathesis. For the removal of tonsils or adenoids, 
chloroform should not be employed. 

Nitrous oxide, while very useful in older children, as in adults, for 
momentary operations, is not well borne by infants. It produces so early 
and so deep asphyxia that its prolonged use may be fraught with serious 
danger. 



PART II. 



SECTION I. 
DISEASES OF THE NEWLY BORN. 

CHAPTER I. 
ASPHYXIA. 

The lungs in the full-term foetus are of uniform dark red colour, 
and show very distinctly upon their surface the lobular divisions. They 
are firm and solid and readily sink in water. The connective tissue is 
very abundant, and forms distinct fibrous septa, which stretch through 
the lungs in every direction. 

Inflation of the lungs begins with the first cry uttered by the in- 
fant as it is born into the world. The parts first expanded are the 
anterior borders of the lungs, then the upper lobes, and finally the lower 
lobes posteriorly. The superficial lobules are nearly always expanded 
before those in the interior of the lung. The inflation is sometimes 
irregular, because of the accumulation of mucus in some of the bronchial 
tubes. The right lung is frequently stated to be expanded earlier than 
the left. Although this is often the case, there is no uniformity in this 
respect. The important point to be remembered is, that the parts last 
inflated are the posterior portions of the lower lobes. The expansion of 
the lungs is a gradual process, and in healthy infants it is probably not 
complete much before the end of the second day. In delicate children 
it may be postponed for several days, or even weeks. The above state- 
ments are based upon post-mortem observations upon infants dying from 
various causes during the first weeks. It has often been a matter of 
great surprise to find at autopsy on an infant two or three days old, that 
less than one-half of the lung tissue was expanded, although the child 
had breathed well and shown no signs of atelectasis. Under normal 
conditions at full term inflation of the lungs takes place very readily, but 
not so readily in premature or delicate infants, on account of the feeble- 
f tli<- respiratory muscles. The longer it is postponed after birth 
the more difficult floes it become, on account of the changes which occur 
in the collapsed air vesicles. The condition of the child in utero may 
be described as one of foetal apnoea, its oxygen being received and its 
68 



ASPHYXIA. 69 

carbon dioxide discharged through the placenta, which is essentially 
the organ of respiration at this period. This condition is interrupted 
by cutting off the supply of oxygen and the accumulation of carbon 
dioxide in the blood. Which of these is the important factor in induc- 
ing pulmonary respiration has been much debated; but the best experi- 
mental evidence seems to show that it is the want of oxygen which 
stimulates the respiratory centres. 

Under the term " asphyxia " may be included all cases in which 
primary respiration is not spontaneously established with sufficient force 
to maintain life. Usually there is no attempt at pulmonary respiration 
until after the birth of the child, but it may occur in utero or at any 
stage of parturition. Asphyxia may be of intra-uterine or extra-uterine 
origin. 

Etiology. — 1. Intra-uterine Asphyxia. — The maternal causes include 
any disturbance of the placental circulation during labour — anything 
which prolongs the second stage of labour, convulsions, haemorrhage, 
the use of ergot in the second stage, or, finally, the death of the mother. 
The causes relating to the child are pressure upon the cord, multiple 
winding of the cord about the neck, early separation of the placenta, 
and pressure upon the brain. If the respiratory stimulus comes before 
the birth of the child, the effort at respiration may cause the entrance 
into the mouth and air passages of amniotic fluid, mucus, blood, me- 
conium, etc. 

2. Extra-uterine Asphyxia. — This condition is a much less common 
one. It arises from causes quite apart from those above mentioned, and 
depends upon malformations or intra-uterine disease of the organs of 
respiration, circulation, or of the brain. It may be secondary to an 
injury of any of these organs received during parturition. It is also 
seen in premature infants, where it depends upon the feeble development 
of the nerve centres and respiratory muscles and upon the soft, yielding 
chest walls. 

Lesions. — In infants dying of intra-uterine asphyxia there are seen 
the usual changes found in death from suffocation, together with the 
effects of attempts at breathing in utero. There is general congestion of 
all the viscera, particularly of the brain and its meninges, the liver, and 
the. lungs. They may show small, punctate haemorrhages, and occa- 
sionally large extravasations. Blood or bloody serum may be found in 
any of the serous cavities. The right heart is overdistended with dark, 
soft clots, and the blood generally is more fluid than normal. The 
lungs may contain no air, but more frequently there are small, scattered 
areas in which lobular inflation has taken place. If the child has lived 
several hours there are larger areas of expanded lung, especially in the 
upper lobes, and these may even be emphysematous, if artificial inflation 
has been employed. In the mouth, nose, larynx, and even as far as the 



70 DISEASES OF THE NEWLY BORN. 

fines! bronchi, there may be found aspirated materials — amniotic fluid, 
Mood, mucus, or meconium. In extra-uterine asphyxia there are organic 
changes in 1 ho viscera— malformations of the lungs or the heart, intra- 
uterine pneumonia or pleuritic effusion, malformation of the diaphragm 
and sometimes o( the brain. 

Symptoms. — Under normal conditions the newly-born infant begins 
at once to scream and to use his limbs, the purplish colour of the skin 
giving place in a i'cw moments to a rosy pink. In the first degree of 
asphyxia — asphyxia livida — the child is deeply cyanosed. Either no 
attempt whatever is made at respiration, or it is superficial and repeated 
only at long intervals. The pulse is slow, full, and strong. The vessels 
of the cord are distended. Muscular tone is preserved, and also cutaneous 
irritability, so that with the application of almost any kind of external 
stimulus, respiration is excited and the symptoms disappear. 

In the second degree — asphyxia pallida — the picture is quite a dif- 
ferent one. The face is pale and deathlike, though the lips may still be 
blue. The heart's action is weak, and by palpation can rarely be felt 
at all. By auscultation the sounds are feeble, irregular, and usually slow. 
The cord is soft, pale, and flaccid, and its vessels nearly empty. The 
sphincters are relaxed, and meconium oozes from the anus. There is 
entire loss of tone in the voluntary muscles, so that the extremities and 
entire body seem perfectly limp. Cutaneous sensibility is abolished. 
The extremities are often cold. There may occur a few short, convulsive 
contractions of the respiratory muscles, but these are without effect and 
soon cease. Unless such cases receive the most prompt and efficient treat- 
ment, the heart's action becomes more and more feeble until it ceases 
and death occurs. Other cases are partly resuscitated and may survive 
for a few hours or days, when they gradually sink, respiration becoming 
more and more feeble in spite of all efforts to maintain it. Between 
these two extremes all degrees of severity are seen. 

In extra-uterine asphyxia there may be some attempts at voluntary 
respiration continuing for several hours, sometimes for a day or two, 
but this may be inadequate to sustain life. 

Diagnosis. — Almost the only condition with which asphyxia is likely 
to be confounded is cerebral compression from a meningeal haemorrhage. 
The difficulties in the case are much increased by the fact that the two 
conditions are not infrequently associated. It may then be impossible to 
tell that in addition to asphyxia, intracranial haemorrhage is present. 
If the haemorrhage is extensive and the asphyxia only moderate, a diag- 
nosis is possible in most of the cases. In haemorrhage there is often a 
history of undue compression during delivery — sometimes the use of 
forceps. The fontanel is bulging; there is coma, and there may be 
paralysis. The respiratory murmur may be quite strong for several 
hours, but it gradually fails as the child becomes completely comatose. 



ASPHYXIA. 71 

Anaemia resulting from a large haemorrhage, like that due to rupture of 
the cord, may simulate the severe form of asphyxia. 

Prognosis. — This depends upon the grade of asphyxia and the treat- 
ment employed. There is hut little tendency to spontaneous recovery in 
any form. In the milder cases recovery is almost invariable with any 
intelligent treatment. In the severest cases the outcome is always doubt- 
ful, although by persistent effort many infants that are apparently 
hopeless may be saved. In a prognosis as to the ultimate result, the 
frequent complication of asphyxia with meningeal haemorrhage should 
always be kept in mind. Apart from this complication it is doubtful 
whether asphyxia has anything to do with the production of idiocy. 

Treatment. — In every case the first step is to clear the mouth and 
pharynx of mucus by means of the finger covered with absorbent cotton. 
In the milder forms respiration is usually excited either by spanking the 
child or the alternate use of hot and cold baths. If the hot bath is 
employed, the water should be from 104° to 108° F. and always tested 
by a thermometer. After a moment the child should be dipped into very 
cold water, or the body may be douched with it. In the livid cases relief 
is often afforded by allowing the cord to bleed for a few moments before 
ligation. The loss of half an ounce of blood is ordinarily sufficient. 
Simply swinging the child in the air is a powerful stimulus to respira- 
tion. The above means will suffice in the great majority of cases. In 
the more severe forms, however, these are inadequate. There is no 
response whatever to external stimulation, either by heat or mechanical 
irritation. In these cases two methods of resuscitation may be employed : 
artificial respiration and direct inflation of the lungs. 

One of the most widely employed methods of inducing artificial 
respiration is that of Schultze. The infant is grasped by both axillae in 
such a way that the thumbs of the physician rest upon the anterior surface 
of the chest, the index fingers in the axillae, and the remaining fingers 
extending across the back. The child is thus suspended at arm's length 
between the knees of the physician, the feet downward and the face 
anterior. The body is now swung forward and upward, until the physi- 
cian's arms are nearly horizontal. This produces the inspiratory effort. 
When this point is reached, an arrest in the swinging causes flexion of 
the trunk, the head now being directed downward, the lower extremities 
fall toward the physician until the whole weight of the body rests upon 
the thumbs. In this way expiration is produced. Lusk cautions against 
the employment of this method if the heart's action is very feeble, as it 
may cause the heart to stop altogether. This method should be used 
with care and skill; clumsy and too forcible manipulation has resulted 
in many serious injuries to the viscera and fractures of ribs or clavicles. 

A method introduced by Dew has been extensively employed in New 
York. The infant is grasped in such a way that the neck rests between 



72 DISEASES OV THE NEWLY HORN. 

the thumb and forefinger of the loft hand, the head being allowed to 
fall far backward, the upper portion of the back resting upon the palm 
of the hand; with the right hand the knees are grasped between the 
thumb ami fingers, the thighs resting against the palm of the hand. 
Inspiration is produced by depressing the pelvis and lower extremities, 
thus causing the abdominal organs to drag upon the diaphragm, and at 
the same time gently bending the dorsal region of the spine backward. 
In expiration the movement is reversed, the head being brought forward 
and flexed upon the thorax, while at the same time the thighs are flexed 
so as to bring them against the abdomen. The body is thus alternately 
folded upon itsel £ and unfolded as the movements are carried on. If there 
is much mucus in the mouth, the movement of expiration should first be 
made with the body completely inverted. This method is simple, efficient, 
and much less fatiguing than that of Schultze when it is to be main- 
tained for a long time. It is also of great advantage in that it can be car- 
ried on while the child is in the hot bath, one of the greatest objections to 
the method of Schultze being the loss of animal heat incident to its use. 

In all cases where artificial respiration is used the first movement 
should be that of expiration, to expel, so far as possible, mucus or other 
foreign substances from the air passages. The movements should be 
made from eight to twelve times a minute, and not too forcibly, the 
child being kept in the hot bath between the movements, and as much 
as possible during them. As long as the heart beats resuscitation is 
possible, and the case should not be abandoned. 

Direct inflation of the lungs by the mouth-to-mouth method should 
not be employed. 

An ingenious apparatus for artificial inflation of the lungs has been 
devised by Carrel of the Eockefeller Institute, making use of Meltzer's 
method of the continuous insufflation of air. A flexible catheter con- 
taining a wire stylet is introduced into the lar} r nx. To the catheter is 
then attached the apparatus shown in Fig. 15. By means of the double 
bulb a continuous flow of air is maintained. The manometer shown at A 
measures the pressure employed and is a guide by which one is prevented 
from using an excessive amount of force. When the pressure employed is 
normal the mercury in the descending and ascending arms of the curved 
tube stands at about the same level; if an excessive amount of pressure 
is used, the mercury will be forced up into the bulb. Although this has 
been as yet very little employed in infants it has been extensively used 
in resuscitating animals and seems to fulfill all the indications better 
than any apparatus hitherto suggested. It is so simple of construction 
that it can easily be put together by any instrument maker. 

The method introduced by Laborde, of making rhythmical traction 
upon the tongue ten or twelve times a minute as a means of exciting res- 
piration, is sometimes very useful in conjunction with other methods. 



CONGENITAL ATELECTASIS. 



73 



Faradisation of the phrenic is of undoubted value, but somewhat difficult 
of application. 

In cases of asphyxia it is not enough to make the child cry. The 
deep respirations should be made to continue, for very often it happens 




Fig. 15. — Carrel's Apparatus for Inflating the Lungs. 

that resuscitation is only partial, and that the child after six or eight 
hours lapses into its previous condition. All severe cases require close 
watching for the first twenty-four or thirty-six hours, as a repetition of 
the treatment is often necessary. 



CHAPTEE II. 



CONGENITAL ATELECTASIS. 

This condition is one in which there is a persistence of the foetal state 
in the whole or in any part of the lung. 

Atelectasis is the pathological condition with which asphyxia of the 
newly born is usually associated. In most of the -cases the condition of 
atelectasis is completely overcome by the means employed in resuscita- 
tion ; in some, however, these means are only partially successful, so that 
a portion of lung of variable extent remains in the foetal condition. 
These are the circumstances in which most of the cases of atelectasis 
arise. But there are others in which there is no history of early asphyxia, 
where the primary respirations, although taking place spontaneously, 
have not been of sufficient force and depth to produce full pulmonary ex- 
pansion. This usually occurs in feeble infants, or in those who are prema- 
ture. The causes of congenital atelectasis are therefore, in the main, 
those mentioned as producing asphyxia. 

Lesions.— In cases where the child dies during the first few days the 
amount of expanded lung is often small, frequently not more than one 



71 DISEASES OF THE NEWLY BORN. 

fourth of the pulmonary area. The expanded portion is usually the ante- 
rior borders oi the Upper lobes. This is often the seat of acute emphy- 
sema. The rest of the lung is still in the foetal state; it is of a brown- 
ish-red colour, very vascular, does not crepitate, and shows the lobular 
outlines both on the surface and on section. With a little force the atelec- 
tatic lung may be completely inflated. 

If children have lived a longer time, nearly the whole of the upper 
lobes and the anterior portion of the lower lobes are usually well inflated. 
These portions are either normal or slightly emphysematous. The pos- 
terior portion of the upper lobes and the lower lobes are almost invariably 
the seat of the atelectasis. On the surface even these portions may pre- 
sent quite a large area of expanded vesicles, but the underlying portion 
may be solid to the touch, and crepitates but slightly. On section it is 
seen that only the most superficial part of the lung is inflated, while the 
interior of the lobe is unexpanded. Small haemorrhages are frequently 
seen beneath the pleura. 

It is usual for both lungs to be affected, and often, but by no means 
uniformly, to about the same degree. It is frequently a great surprise to 
discover that a child has lived for some weeks without presenting any 
signs of cyanosis, although using not more than one-third of its pulmo- 
nary area. This variety of atelectasis closely resembles the hypostatic 
pneumonia of delicate infants, and very often the two conditions are 
associated. It may require the microscope to decide between them. If con- 
genital atelectasis has existed for a considerable time, there are usually 
found evidences of pneumonia. Inflation is not so easy as in recent cases, 
but with force the greater part of the lung can usually be expanded. The 
heart commonly shows the right auricle and ventricle to be distended with 
dark clots, and there is occasionally found a patent foramen ovale or 
some jother form of congenital lesion. The liver and spleen are in most 
cases congested, and the spleen may be considerably enlarged. The mucous 
membrane of the stomach and intestines is sometimes deeply congested. 

Symptoms. — In one group of cases the children are asphyxiated at 
birth, but the attempts at resuscitation have been only partially success- 
ful. Although the patients may live for a few days, there is cyanosis, 
which gradually deepens, and death takes place from asphyxia, exhaus- 
tion, or convulsions. 

In a second group of cases the infants have been asphyxiated at birth, 
and resuscitated perhaps with difficulty, but to all appearance completely. 
They do not thrive, however, remaining small and delicate, gaining very 
little or not at all in weight, and showing poor circulation, cold extremi- 
ties, and occasionally subnormal temperature. It is characteristic of these 
cases that the cry is never loud, strong, and lusty. Some of them will not 
cry at all. Such children may live several weeks. There may develop 
at any time, often quite suddenly and without assignable cause, attacks 



CONGENITAL ATELECTASIS. 75 

of cyanosis with prostration. Children may have several such attacks, 
which do not excite suspicion since they pass away spontaneously. In 
other cases the symptoms are so severe that they may result fatally in a 
few hours, death being frequently preceded by convulsions. If energet- 
ically treated the symptoms may pass away but, reappearing in a few 
hours, or again after a week or more, they gradually deepen in intensity 
until death occurs. 

Two cases that came under my observation in the New York Infant 
Asylum illustrate this point. The infants were twins, ten weeks old 
and delicate. Suddenly at night one child was taken with convulsions, 
became deeply cyanosed, and died in two and a half hours. It had been 
suffering from a slight attack of indigestion for a week previous. The 
other twin had been apparently well on the previous day. Two hours 
after the death of the first child the second was taken with similar symp- 
toms, dying in a few hours. At autopsy I found very extensive atelec- 
tasis involving the posterior part of the upper and the greater part of 
both lower lobes. The lesions were almost identical in the two cases. 
In both, the stomach was greatly distended with food and gas. I have 
repeatedly seen the effect of overdistention of the stomach in producing 
cyanosis in young children, and in this instance I believe it to have been 
the exciting cause of the final symptoms. It was subsequently learned 
that during the six weeks of observation the nurse had witnessed several 
slight attacks of cyanosis in one of the infants. It is of course possible 
that the atelectasis in these cases may have been in part at least acquired. 

I have seen a number of cases, in which there was nothing whatever 
to attract attention to the lungs until the final attack of cyanosis oc- 
curred. In not all of these cases is there a history of asphyxia at birth. 
Some are only puny, delicate or premature, exhibiting during the early 
weeks of life all the signs of feeble vitality. The subsequent course is 
the same as in those in which there is early asphyxia. The duration of 
life in these cases depends chiefly upon the extent of the atelectasis. 

It is not to be supposed that all cases of congenital atelectasis ter- 
minate fatally. Infants in whom there is every reason to believe that 
atelectasis exists, from the occasional attacks during the first few weeks 
of cyanosis, feeble cry, poor circulation, etc., may under favourable con- 
ditions with improved nutrition recover completely, even though no 
special treatment is directed to the lungs. 

Diagnosis. — The physical signs are of much less value than the symp- 
toms. It should be remembered that the principal seat of the disease 
is the lower lobes posteriorly. Percussion usually gives resonance over 
the entire chest, although this may be somewhat diminished posteriorly. 
There is not, however, so much change as one would expect to find, for 
the collapsed areas are surrounded by others which are overdistended, and 
there are in the midst of the collapsed parts, especially upon the surface, 



76 DISEASES OF THE NEWLY BORN. 

lobules which are inflated. If the two sides arc involved to about the 
same degree, as is often the case, we can gel no difference in the percus- 
sion note over the two lungs, and the change from the normal may be so 
slight as not to be appreciable. Where only one lung is affected a differ- 
ence can usually be made out. The respiratory murmur is rarely bron- 
chial, but generally only feeble in its intensity, and rather ruder in 
quality than normal. The cardiac sounds may be transmitted with ab- 
normal intensity. As in the case of percussion, if only one lung is 
affected this is of some value in diagnosis, but it is not sufficiently 
marked to be readily recognised when both sides are involved. Occa- 
sionally rales are present. 

Treatment. — In the newly-born child, whether asphyxiated or not, 
the physician should see to it that the infant not only cries, but does so 
loudly and strongly, and that this cry is repeated every day. If children 
do not cry naturally they must be made to do so by the alternate use of 
the hot and cold bath, as in cases of asphyxia, or by mechanical means, 
like spanking. This should be repeated at least twice a day, and con- 
tinued for from fifteen to thirty minutes. It may seem cruel, but it is 
often the only means of saving life. Expansion of the lungs is much 
more easily induced during the first few days of life, becoming more and 
more difficult the longer it is delayed. Provided the condition is recog- 
nised, treatment is fairly successful. In institutions where delicate in- 
fants spend most of the time in their cribs, atelectasis is likely to be 
found. An infant needs exercise, and this is often only to be obtained by 
taking the child from its crib several times a day, by general friction, 
massage, the stimulus of fresh air, etc. jSTothing is more certain to per- 
petuate atelectasis than to allow the infant a life of feeble vegetative 
existence. Food and feeding must be carefully attended to, but even 
these are of less importance than the maintenance of the animal heat. 
The temperature is often subnormal, and should be closely watched. If 
there is difficulty in keeping the child warm it should be rolled in cotton 
and surrounded by hot bottles, or kept in an incubator during the first 
few weeks. During attacks of cyanosis the same means are to be em- 
ployed as in cases of asphyxia of the newly born — cutaneous stimulation 
and artificial respiration — the administration of drugs being of little or 
no value, but oxygen may be of assistance. 



CHAPTER III. 

ICTERUS. 

Several varieties of icterus are met with in the newly born. 
1. It is often seen in the various forms of pyogenic infection. In 
such cases the icterus is usually mild. 



ICTERUS. 77 

2. It may be due to congenital malformations of the bile-ducts. 

3. It may depend upon interstitial hepatitis. 

4. The most frequent of all varieties is the so-called idiopathic 
icterus, sometimes spoken of as " physiological " icterus. 

In the cases included under the first and second heads icterus is a 
minor symptom. The other varieties are sufficiently important to require 
separate consideration. 

Malformations of the Bile-ducts. — The common bile-duct is the most 
frequently affected. There may be atresia at the point where it opens 
into the intestine, the duct may be represented by a fibrous cord, or it 
may be absent altogether. In many cases this is the only lesion; in 
others it is associated with an impervious hepatic or cystic duct; in still 
others the common duct is normal, but the cystic or hepatic ducts are 
impervious. 

At autopsy all the organs are usually found intensely jaundiced, par- 
ticularly the liver. In recent cases this is very much swollen, but pre- 
sents no marked organic changes. In cases which have lasted several 
months there is commonly found chronic interstitial hepatitis, sometimes 
to a very marked degree. This was present in nine of the fifty cases col- 
lected by Thomson. The gall-bladder is usually small, and often rudi- 
mentary. In cases of atresia of the common duct it may be greatly dis- 
tended. 

The condition of the bile-ducts is ascribed to an error in development 
and subsequent catarrhal inflammation. There does not seem to be suf- 
ficient evidence to prove that hereditary syphilis is an etiological factor 
of much importance. This was present in but five of Thomson's 
cases. 

Symptoms. — The most striking symptom is jaundice, which is usu- 
ally noticed a day or two after birth, and steadily increases until it 
becomes intense. The other symptoms of obstructive jaundice are pres- 
ent. The urine is coloured a dark brown or bronze by bile pigment, the 
stools are white, and tests show bile pigment to be absent, except in cases 
where malformation is limited to the cystic duct. The liver as a rule 
is much enlarged. The spleen is often swollen. Haemorrhages beneath 
the skin or from any of the mucous membranes are quite common. Vom- 
iting is usually absent. In most cases there is progressive wasting, and 
death from inanition within the first few weeks. Of Thomson's fifty 
cases, nine lived less than a month, and only eighteen over four months. 
Lotze has reported a case of a child living eight months with an imper- 
vious hepatic duct. A frequent cause of death in the more rapid cases 
is convulsions. 

These malformations cannot be influenced by any treatment. 

Interstitial Hepatitis. — There is seen in newly-born children a form 
of icterus which resembles the foregoing in many particulars, but which 



78 DISEASES OF THE NEWLY BORN. 

may end in recovery. In three such cases which have terminated fatally 
1 have found the Lesions of a general interstitial hepatitis, presumably 
of syphilitic origin. It is not certain that syphilis is always the cause of 
this condition, for the clinical history in some of them gives no evidence 
of this disease. While not a common condition 1 believe it to be more 
frequent than congenital malformations of the bile-ducts with which it is 
often confounded. 

The symptoms and course may he illustrated by the following cases: 
A full-term, well-developed child of eight pounds' weight became jaun- 
diced on the second day. By the fifth day the jaundice was intense; 
stools, pale yellow, and urine deeply bile-stained. Examination at three 
weeks showed both liver and spleen much enlarged. The jaundice was 
very marked for over a month; it was nearly two months before it faded 
entirely. The nutrition of the child was a matter of much difficulty for 
several weeks. The enlargement of the spleen and liver like the jaundice 
disappeared very gradually. There was no other evidence of syphilis in 
this patient nor in the two other children of the family, and no history 
of this disease could be obtained in the parents. Yet the improvement 
which began with the use of mercurial inunctions strongly suggested a 
syphilitic lesion. 

In another case, the symptoms and course of which were almost 
identical, the stools, though nearly white, never failed to give the reac- 
tion for bile. A previous child in this family had died three years before 
at the age of six weeks with persistent jaundice, which had been diag- 
nosticated congenital malformation of the bile-duct. There was no his- 
tory of syphilis; but the mercurial inunctions seemed equally efficacious 
as in the first case cited. 

Not much need be added to the symptoms described. Both in those 
recovering and in the fatal cases there was no fever and no ascites; but 
there was much tympanites. The application of the Wassermann test 
will no doubt aid in clearing up the etiology of these cases. Other evi- 
dences of syphilis should always be carefully sought, but in all the cases 
I have seen, even those ending fatally and with syphilitic lesions at 
autopsy, clinical evidence of syphilis during life was wanting. A care- 
ful trial of antisyphilitic treatment should, therefore, be made in every 
case of protracted jaundice in a newly-born child. One should not be 
too ready to make the diagnosis of malformation of the bile-ducts and 
regard the case as hopeless. Nor does the fact that the child recovers 
without antisyphilitic treatment exclude syphilis as the cause, for one of 
Still's cases recovered from the jaundice and died at the age of nineteen 
months, the autopsy showing lesions evidently syphilitic. 

Physiological or Idiopathic Icterus. — In 900 consecutive births at the 
Sloane Maternity Hospital icterus was noted in 300 cases. In 88 it was 
intense, in 212 it was mild. According to the statistics of various lying- 



ICTERUS. 79 

in hospitals of Germany, it was found in from 40 to 80 per cent, of all 
infants. In the 300 cases just referred to, icterus was noticed on the 
first day in 4, on the second day in 19, on the third day in 72, on the 
fourth day in 86, on the fifth day in 67, and on or after the sixth day 
in 44. From the second to the fifth day is therefore the usual period for 
its appearance. 

It usually increases in severity for one or two days and then slowly 
disappears. The average duration in the mild cases is three or four days ; 
in those of moderate severity about a week; in the most severe cases it 
may last for two weeks. The icterus is first noticed in the skin of the 
face and chest, then in the conjunctivae, then in the extremities. The 
skin varies in colour from a pale to an intense yellow. The urine in most 
cases is normal. It sometimes is of a light-brown colour, and only in the 
most severe cases does it contain bile pigment. According to Runge, both 
urea and uric acid are produced in larger amounts than in children not 
icteric. The stools are unchanged, the normal yellow evacuations occur- 
ring in the icteric as early as in those not affected. 

According to some observers, in infants who are icteric the initial loss 
in weight is greater and the subsequent gain slower than in other chil- 
dren. This is not borne out by the Sloane statistics. Of the 300 icteric 
children, 155 made satisfactory progress in every respect and gained rap- 
idly. The progress in 106 cases was said to be " fair " — i. e., at the time 
of discharge, usually on the tenth day, a slight gain in weight was noted. 
The remaining 39 did badly, not gaining in weight and showing other 
symptoms of malnutrition. The proportion of icteric infants who did 
well, moderately, and badly, was practically the same as of the other 
children in the institution not suffering from icterus. Icterus occurs with 
equal frequency in both sexes. According to Kehrer, it is more frequent 
in first children than in later ones, and considerably more frequent in 
premature children than in those born at term. The presentation, the 
duration of labour and its character — whether natural or artificial — have 
no influence upon the production of icterus. As a rule icteric children 
appear in other respects healthy, but in those below the average size the 
icterus is apt to be more intense. 

Few subjects have given rise to wider speculation than this form of 
icterus. Its exact pathology is at present unknown. It is generally 
held that the icterus is due to resorption, and is hepatogenous in origin. 
The most recent and reasonable theory advanced is that of Abramow, 1 
who considers it to be an anomaly of secretion of the liver cells; it is 
due to an active secretion of bile which occurs soon after birth and which 
is poured out into capillary ducts obstructed by thick bile which is pres- 
ent at birth ; from these conditions there results an overflow of bile into 

1 Knopfelmacher, Jahrbuch fur Kinderheilkunde, Vol. 17; 1908. 



SO DISEASES OF THE NEWLY BORN. 

the lymph and blood vessels, producing jaundice. Usually the more 
feeble the child the more intense is the icterus. 

In jaundiced infants who have died from accident or other causes the 
skin and almost all the internal organs arc found icteric. There is also 

staining oi the internal coat of the arteries, the endocardium, the peri- 
cardium, and the pericardia] fluid. Sometimes the subcutaneous connect- 
i\c tissue is yellow, also the brain and cord ; the spleen and kidneys only 
in the most severe cases. The liver is rarely discoloured. The bile- 
duets are normal. 

This jaundice is never fatal, and in itself is not serious. Other 
conditions, such as atelectasis, may co-exist, which may make the ease 
grave. 

Diagnosis of the Different Varieties of Icterus. — The diagnosis of 
physiological icterus is to be made from sepsis, malformations of the 
bile-ducts, and interstitial hepatitis. In sepsis the symptoms usually 
appear at a later date ; there is fever, rapid wasting, and often a dis- 
charge from the umbilicus and local symptoms indicating peritonitis, 
arthritis, pneumonia, or meningitis. In malformations of the bile-ducts 
the icterus is usually more intense and appears almost immediately after 
birth ; bile is absent from the stools ; the icterus is persistent, and the 
symptoms go progressively from bad to worse, always ending fatally. 
In interstitial hepatitis the icterus develops at about the same time as, 
but is generally more marked than, in the physiological variety. Both 
liver and spleen are usually enlarged. The stools may be white, but 
still give a faint bile reaction. 

Physiological icterus requires no treatment. 



CHAPTER IV. 

THE ACUTE INFECTIONS OF THE NEWLY BORN. 

It is possible for the newly-born infant to suffer from almost all of 
the common infectious diseases. Smallpox probably has been most fre- 
quently observed. In rare instances, influenza, typhoid fever, malaria, 
and pneumonia have occurred in the first days of life. As the mothers 
in many instances were suffering from the diseases during or just prior 
to delivery, the infants appear to have been infected before birth through 
the circulation of the mother. In other cases, especially in pneumonia, 
influenza, and gastro-enteritis, infection may take place soon after birth. 
The symptoms of these diseases in the newly born differ very little from 
those occurring in any other young infant. In addition to the diseases 
mentioned, there are other forms of infection which belong especially 
— some of them exclusively— to the newly born. 



THE ACUTE PYOGENIC DISEASES. 81 



THE ACUTE PYOGENIC DISEASES. 

Under this head are grouped various infections of the newly born, 
due to the entrance of the common pyogenic bacteria. They have been 
designated as puerperal fever of the child, also as pyaemia or septicaemia, 
or simply as sepsis of the newly born. A variety of pathological and 
clinical conditions are met with. In some cases there is only a localised 
external inflammation, often terminating in abscess formation; some- 
times one or more of the internal organs is affected; occasionally a 
general blood infection — a true septicaemia — is seen without any note- 
worthy local lesion; finally, there are the cases attended by the pro- 
duction of multiple abscesses in the viscera, joints, or cellular tissue 
— a true pyaemia. Formerly infections of this class were very com- 
mon, especially in large lying-in hospitals; but, owing to the general 
adoption of the methods of aseptic midwifery, they have steadily dimin- 
ished. 

Etiology. — The source of infection of the child may be the vaginal 
secretion of the mother or, in rare cases, the mother's milk. Although 
it has been shown that in a great proportion of the cases the milk of a 
woman suffering from mastitis or from septicaemia contains pyogenic 
germs, still the taking of these into the stomach is not likely to infect 
the infant. More frequently the child is infected by the nurse in the 
process of dressing the cord, bathing, or cleansing the mouth or eyes, 
possibly after having attended to the needs of a septic mother or another 
child. Infection may be carried by the physician, by instruments, or by 
the dressings of the cord. Infection may occur through any wound or 
abrasion of the skin. 

Infection through the umbilicus may take place either before or after 
the separation of the cord. The infection may take place through the 
umbilicus, yet this may give no external evidence of disease, although 
the umbilical vessels inside the body may contain pus. From this focus 
of infection may arise peritonitis, meningitis, or other inflammations. 
Entering through the mouth, bacteria may lead to infectious processes 
in the throat, the stomach or intestines, and rapidly produce death; or 
the alimentary tract may be the focus from which infection of distant 
parts may arise. 

The micro-organisms chiefly concerned in these infections are the 
common pyogenic bacteria, staphylococcus pyogenes aureus and the strep- 
tococcus. The next in importance is the gonococcus, the role of which, 
especially in cases accompanied by joint suppuration, has only recently 
been appreciated. Pneumococcus infections occasionally complicate the 
others mentioned. While streptococcus infections are in general more 
serious than those due to the staphylococcus, some of the most severe 
ones met with belong to the latter class. 



82 DISEASES OF THE NEWLY BORN. 

Clinical Varieties. — Omphalitis. — In this variety there is inflamma- 
tion of the umbilicus, and cellulitis of the abdominal wall in the im- 
mediate neighbourhood. This results in the formation of an umbilical 
phlegmon. It may terminate in resolution, in abscess, or in gangrene. 
The usual termination is in abscess. These abscesses may be small and 
superficial, or they may be more deeply seated between the abdominal 
muscles and the peritonaeum. Omphalitis usually begins in the second 
or third week of life, before the umbilicus has cicatrised. The process 
may result in erysipelatous inflammation and it may spread to the peri- 
tonaeum. 

Inflammation of the Umbilical Vessels. — This is one of the most 
frequent primary processes in pyaemic infection. The umbilical arteries 
are more frequently involved than the vein. According to Eunge, in- 
flammation of the vessels is always preceded by inflammation of the 
connective tissue which surrounds them, as the poison is taken up by the 
lymphatics and not by the blood-vessels. Omphalitis is frequently pres- 
ent, but in some cases the umbilicus shows nothing abnormal. 

In arteritis the vessels may be involved to any degree: sometimes 
only a short distance from the abdominal wall, sometimes quite to the 
bladder. They contain pus, and often septic thrombi. Saccular dilata- 
tion is frequently present at several points. Pus sometimes exudes from 
the umbilical stump on pressure. The other lesions accompanying 
arteritis are those of pyaemic infection, more or less widely distributed. 
There are frequently peritonitis, suppuration of the joints, erysipelas, 
multiple abscesses of the cellular tissue, sometimes suppurative parotitis. 
Atelectasis is common. Pneumonia was found in twenty-two of Bunge's 
fifty-five cases. 

In cases of phlebitis, the umbilical vein is usually involved for its 
entire length from the abdominal wall to the liver. This may lead to 
an acute interstitial hepatitis going on to suppuration, or to phlebitis 
of the portal vein and some of its branches. In either case there is 
more or less parenchymatous hepatitis, and often multiple abscesses of 
the liver, most of the patients being jaundiced. Peritonitis also is a fre- 
quent complication. 

Peritonitis. — This is one of the most frequent pathological processes 
in pyaemic infection, and is very often the cause of death. It is generally 
associated with umbilical arteritis, and often with er} T sipelas. In a 
considerable number of cases it is the most important lesion found. 
It may be localised or general. Localised peritonitis is generally in 
the neighbourhood of the umbilicus or of the liver. It may result in 
adhesions, or in the formation of peritoneal abscesses. More frequently 
the peritonitis is general, and resembles the septic peritonitis of adults. 
There is a great outpouring of fibrin coating the intestines and other 
riseera and the inner surface of the abdominal wall, causing adhesions 



THE ACUTE PYOGENIC DISEASES. 83 

between the abdominal contents. Collections of sero-pus are found in 
the pelvis and in various pockets formed by the adhesions. Sometimes 
blood is present in the exudation. 

The special symptoms which indicate peritonitis are vomiting, ab- 
dominal tenderness and distention, and protrusion of the umbilicus. 
The abdominal enlargement is chiefly from gas, but may be partly from 
fluid. There are present thoracic respiration, dorsal decubitus, flexion 
of the thighs and fixation of all the muscles, the child lying perfectly 
quiet. The temperature is usually but not necessarily high. Marked 
leucocytosis is generally present. 

Pneumonia. — The most common form seen is pleuro-pneumonia. 
There is an abundant exudate of grayish-yellow fibrin covering the 
lung. Occasionally collections of pus are found in the sacs formed by 
the adhesions. Serous effusions are rare. The pulmonary lesion consists 
usually in a broncho-pneumonia, with consolidation of larger or smaller 
areas in the lungs — more often in the upper than in the lower lobes. 
It is not uncommon for minute abscesses to be found in the lung at 
various points. There is a purulent bronchitis of the larger and smaller 
tubes. 

The s} T mptoms are obscure and often indefinite. The only character- 
istic ones are cyanosis and rapid respiration, with recession of the chest 
walls on inspiration. The physical signs are inconstant and uncertain. 
Pneumonia often cannot be diagnosticated during life. In most of the 
fatal cases of pyogenic infection, whatever its type, there is found some 
involvement of the lungs. The changes are most extensive in cases in 
which the serous membranes are involved. 

Pericarditis is rare and usually associated with pleurisy. Endocar- 
ditis is very rare. Hirst has, however, reported a case. 

Meningitis. — When meningitis is present it is usually associated with 
peritonitis or with pleurisy. The lesions are those of acute purulent 
meningitis with a copious exudation, sometimes associated with menin- 
geal haemorrhages, or with acute encephalitis and the production of 
multiple minute abscesses in the cortex. The local symptoms are often 
not marked, and are sometimes very obscure. The most characteristic 
are stupor, dilated pupils, opisthotonus, bulging fontanel, general rigid- 
ity, convulsions, and occasionally localised paralyses. The temperature 
is generally high. A positive diagnosis can generally be made by lumbar 
puncture, by which means also the exciting cause of the meningitis can 
usually be determined. 

Gastro-enteritis. — Diarrhoea is a frequent symptom in all septic cases, 
constipation being rarely present. In many instances vomiting is a 
prominent symptom. In a small proportion of cases the most important 
local lesions are in the intestines, generally in the nature of a superficial 
catarrhal inflammation. 



84 nisi \si s or THE NEWLY BORN. 

Stomatitis, Infections of the oral mucous membranes are not in- 
frequent hut sometimes very severe. Thej may be due to the strepto- 

118, staphylococcus aureus or the gonococcus. An occasional compli- 
cation of oral infections is abscess of the parotid. 

eomyelitis. — Ailard has reported a series of cases in which, after 
the general and local symptoms of pyogenic infection had existed for 
some time, suppuration incurred over various bones, especially the 
humerus, tibia, metatarsal hones, sacrum, etc. Trephining revealed the 
lesions of osteomyelitis. The abscesses usually made their appearance 
between the fourth and the sixth week. The most rapid case died 
on the fourteenth day, and none lasted more than two and a half 
months. 

Joint Suppuration. — In certain pysemic cases, and in some in which 
there are no other symptoms, acute suppuration in the joints occurs. 
This may come on very acutely in the first or second week, or more 
slowly as late as the second or third month. In the acute cases it is 
exceptional to have but one joint involved; frequently there are four or 
five. The small joints are rather oftener affected than the large ones, 
but almost any articulation in the body may be involved. "With multi- 
ple joint suppuration there are present the general symptoms of pyaemia 
— high temperature, marked prostration, wasting, and usually secondary 
visceral inflammations develop. In those which occur late, or which 
develop more slowly, fewer joints are involved, often but a single one, 
the febrile symptoms are less marked or wanting. In my own experience, 
the organism most frequently found in these cases is the gonococcus; 
next to this in importance is the streptococcus and occasionally the 
pneumococcus is found. The joint lesion is usually a superficial one, 
the bones generally escaping. The gonococcus cases probably occur most 
frequently as a complication of ophthalmia; but I have seen several in 
which ophthalmia was not present and where the point of entry could 
not be determined. 

Many of the abscesses supposed to be in the joints are shown at opera- 
tion to be at the epiphyses; from this source the joints may be involved 
secondarily. A point to be remembered in the diagnosis of these joint 
inflammations is their resemblance to the epiphysitis of hereditary syph- 
ilis and other symptoms of that disease should be looked for. The con-' 
fusion is increased by the fact that in syphilitic cases abscesses may 
follow as a consequence of a secondary infection. 

Abscesses in the Cellular Tissue. — These are quite frequent, and may 
occur with suppuration in the joints or internal organs, or they may 
exist as the only lesion. They are nearly always multiple and may be 
found in almost any location. They vary in size from that of a small 
pea to one containing half an ounce of pus. They are due to the intro- 
duction of pyogenic germs, usually staphylococci. Their course is benign, 



THE ACUTE PYOGENIC DISEASES. 85 

and they require no treatment except incision and cleanliness. When 
there is a disposition to their continued formation, the skin should be 
washed with an antiseptic solution. 

Erysipelas. — This is seen especially during the first two weeks of 
life, and usually starts from the umbilicus or some abrasion of the skin, 
most frequently about the genitals or the scalp. When originating at 
the umbilicus it is generally complicated by other lesions, such as peri- 
tonitis and umbilical phlebitis. If it starts from any other part of the 
body it may be uncomplicated. Erysipelas beginning at the umbilicus 
gives rise to an area of induration and a circumscribed erythema. At 
first it may resemble a simple cellulitis; but the steadily increasing area 
of elevated induration and redness soon indicates the nature of the in- 
flammation. From whatever point starting, the erysipelatous inflam- 
mation, owing to the feeble resistance of the tissues, in most cases 
spreads widely. The entire abdomen, chest, and back may be involved, 
and it may even spread to the extremities. Nearly the whole trunk may 
be affected in four or five days. It usually involves only the skin and 
superficial cellular tissue; but it may involve the deeper areolar planes 
and terminate in diffuse suppuration, or even in gangrene. 

The constitutional symptoms are severe : great prostration, continu- 
ously high temperature — 102° to 105° F. — rapid wasting, and frequently 
vomiting, diarrhoea, or convulsions are present. The disease is always 
serious, and usually fatal. It is often complicated by broncho-pneu- 
monia. General oedema of the affected parts may persist for a few weeks 
after the inflammation subsides. 

Distribution of the Lesions. — The frequency of the different visceral 
lesions in eighty-seven autopsies published by Bednar was as follows: 
Peritonitis in twenty-nine, pneumonia in fifteen, pleurisy in ten, menin- 
gitis in nine, meningeal haemorrhage in eight, encephalitis in eight, cere- 
bral haemorrhage in four, entero-colitis in five, pericarditis in four. In 
thirty-one cases there was umbilical arteritis, and in nine cases umbilical 
phlebitis. There was one case each of pulmonary haemorrhage, pleural 
haemorrhage, acute hydrocephalus, acute bronchitis, and suppuration in 
the cellular tissue. Eunge's later observations of thirty-six cases showed 
umbilical arteritis in thirty, umbilical phlebitis in three, and normal 
umbilicus in three. He found pneumonia in twenty-two of fifty-five 
cases. Other lesions frequently associated are atelectasis, swelling and 
softening of the spleen, cloudy swelling of the liver and kidneys, occa- 
sionally with foci of suppuration in these organs. 

General Symptoms. — These may begin at any time during the first 
ten days — very rarely after the twelfth day. Fever is an exceedingly 
variable symptom — it may be very high ; it may be almost absent ; oc- 
casionally there is subnormal temperature. The course of the tempera- 
ture is very irregular. Wasting is constant and quite rapid. It depends 



8(3 DISEASES OF THE NEWLY BORN. 

upon the inability to take and digest l'ooi\, upon the intestinal complica- 
tions, and upon infection. In quite a Dumber of cases wasting is almost 
the onlv symptom. Icterus is common; in many of the worst cases it 
is intense. It is met with where the liver is the seat of an acute paren- 
chymatous or acute suppurative inflammation, and in many other cases 
where it depends apparently upon the Wood changes. Haemorrhages 
are common, and may he the direct cause of death. They may come 
from the umbilicus, the intestine, or almost any mucous membrane. 
They are sometimes subcutaneous, causing a general hemorrhagic erup- 
tion. Xeryous symptoms are generally present, and are sometimes 
marked. They are restlessness, rolling of the head, a constant whining 
cry. twi tchings of the muscles of the extremities or face, stiffening of 
the body, more rarely general convulsions. Late in the disease, dulness 
and stupor are present. The pulse is rapid and w r eak and the respirations 
are often irregular, even when there is no cerebral complication. Diar- 
rhoea is frequent; the stools are green, brown, sometimes black from 
the presence of blood, and are often very foul. Vomiting is less com- 
mon. In addition to these there are symptoms due to the various forms 
of local inflammation — peritonitis, meningitis, pneumonia, erysipelas, 
subcutaneous suppuration and gangrene, these all being found in vary- 
ing degrees and in various combinations. 

Prophylaxis. — Pyogenic infection of the child, like puerperal fever in 
the mother, may be considered a preventable disease. Its occurrence is 
usually due to a failure to carry out proper rules regarding cleanliness 
and asepsis in connection with delivery. The statistics of the Moscow 
Lying-in Asylum, published by Miller in 1888, show that previous to 
the general introduction of aseptic methods, from six to eight per cent 
of all infants born in the institution died from some variety of infection. 
In twenty-three hundred successive , labours at the Sloane Maternity 
Hospital, covering about eight years, not a single marked case occurred. 
From these figures it will be evident that in the vast majority of cases 
the occurrence of a case of infection of a serious nature is the fault of 
the physician or nurse in attendance. 

The umbilicus should be cleansed and treated like any other fresh 
wound. Dry dressing should invariably be employed, and sterilised 
gauze or salicylated cotton in preference to household linen. If suppu- 
ration occurs at the time the cord separates, the parts should be cleansed 
daily with a bichloride solution, and a wet dressing of the same applied. 
The ligatures and everything which comes in contact with the umbilical 
wound should be sterilised. Careful attention should be given to the 
mouth, genitals, and all the muco-cutaneous surfaces, to prevent excoria- 
tions and intertrigo. Finally, every septic case occurring in an insti- 
tution should be immediately isolated. A nurse in charge of a septic 
mother should not have the care of the infant. 



OPHTHALMIA. 87 

Prognosis. — Pyogenic infections in the newly born, even in their 
mildest forms, are serious, and in their most severe forms almost always 
fatal. Very few cases recover in which erysipelas or any important 
visceral inflammation is present. The resistance of these patients is so 
feeble that the tendency of every inflammation is to spread, until they 
die from exhaustion. Only patients with localised inflammations, such 
as those of joints, skin, etc., are likely to get well. 

Treatment. — This practically resolves itself into the treatment of in- 
dividual symptoms as they arise. Wherever suppuration occurs, external 
abscesses should be evacuated and treated antiseptically. For the local 
inflammations of the lungs, peritonaeum, and brain, little or nothing can 
be done in the way of direct treatment. Such inflammations are to be 
prevented, but can seldom be cured. The general indications are to look 
closely to the child's general nutrition by careful attention to all details 
of nursing and feeding, using stimulants whenever required by the con- 
dition of the pulse. For a local application in erysipelas, nothing in my 
experience has proven better than ichthyol ointment, ten to twenty-five 
per cent strength. It should be applied daily, spread upon muslin, 
which is then covered by gutta-percha tissue to prevent drying. In a 
disease so fatal as erysipelas, by ordinary treatment, vaccines should 
certainly be tried. In some cases they seem to have been of undoubted 
value. 

OPHTHALMIA. 

Ophthalmia of the newly born is to be classed among the pyogenic 
diseases. It usually consists in a purulent conjunctivitis. In the more 
severe cases there may be ulceration of the cornea, and even perforation 
into the anterior chamber of the eye. 

The highly infectious nature of this ophthalmia is established. In 
the most severe cases the micro-organism generally found has been the 
gonococcus; but in the milder forms the gonococcus may be absent, and 
any of the common pyogenic germs may be found. In the gonococcus 
cases the infection occurs during labour, from the secretions of the 
mother, from the examining fingers of the physician, or from instru- 
ments; or after birth from infected cloths and other materials which 
come in contact with the eye. Healthy lochia produce only a catarrhal 
inflammation. The infection occurring after birth may take place at 
any time. That due to gonococcus infection from the mother is 
generally manifested on the third day, and is often virulent from the 
outset. 

The symptoms are swelling of the lids, chemosis, copious purulent 
discharge, sometimes haemorrhages from the lids, ulceration, and there 
may even be sloughing of the cornea. The course of the disease depends 
upon the cause and upon the treatment employed. In the cases not 



88 DISEASES OF THE NEWLY BORN. 

due to the gonococcus the course is generally benign, and with ordinary 
cleanliness usually results in recovery without any permanent damage 
to the sight. The gonococcus cases, unless energetically treated from 
the outset, are very frequently followed by permanent loss of vision. The 
best statistics upon the causes of blindness in adults show that from 
twenty-six to thirty per cent of such cases are due to ophthalmia in 
the newly horn. This disease is occasionally complicated by other symp- 
toms of gonococcus infection of a pyasmic nature. Many cases followed 
by acute articular symptoms have been observed. 

Prophylaxis is of the utmost importance. Crede's statistics show that 
in 1874 the frequency of ophthalmia in his lying-in hospital was 13.6 
per cent. In the three years ending 1883, among 1,160 newly-born 
children only one or two cases occurred. The method of prophylaxis 
which he adopted consists in dropping into the eyes of every child, im- 
mediately after birth, one or two drops of a two-per-cent solution of 
nitrate of silver. The general adoption of Crede's method, or of some 
similar means of disinfection, has resulted in a very great diminution in 
the frequency of ophthalmia throughout the world. These prophylactic 
means should be obligatory in all institutions, and should be used in 
all cases in private practice wherever there is any possible suspicion of 
the existence of gonorrhoea. In all other cases the eyes should be care- 
fully cleansed with a saturated solution of boric acid. The use before 
delivery of an antiseptic vaginal douche is theoretically indicated, but 
practically it has been found to be inadequate for the prevention of the 
disease. 

Treatment. — Everything which comes in contact with the eyes should 
be carefully disinfected. All cloths, cotton, etc., used for cleansing 
should be immediately burned. The strictest antiseptic precautions 
should be insisted on to prevent the spread of the infection by nurses. 
In institutions containing infants, severe cases of ophthalmia should 
always be isolated. The most important thing is to keep the eyes clean. 
In severe cases they must be cleansed every twenty minutes, night and 
day. It may be done by irrigation, or by using an eye-dropper with a 
bulbous tip, inserted alternately at the inner and the outer angle of 
the eye, and the fluid injected with force sufficient to empty thoroughly 
the conjunctival sac. Either a saturated solution of boric acid, or a 
1-5,000 solution of bichloride, may be used in this way. Once or twice 
in twenty-four hours two or three drops of a ten-per-cent solution of 
argyrol should be used in each eye after cleansing with sterile water. 
Next to these measures is the use of cold. It may be applied as ice 
compresses which are changed every minute or two from a block of ice 
to the eye. These may be continued one-fourth of the time in the milder 
cases ; in the severe ones almost constantly. When the cornea is involved 
the pupil should be dilated by atropine. If only one eye is affected the 



TETANUS. 89 

sound one should be protected by covering it with a compress kept wet 
with an antiseptic solution. 

TETANUS. 

Tetanus is an acute infectious disease characterised by tonic muscular 
spasm, which increases in severity by paroxysms occurring at longer or 
shorter intervals. It may be limited to the muscles of the jaw (trismus), 
or may affect all the muscles of the trunk, extremities, and neck. 

The germ of tetanus usually gains access to the body of the infant 
through the umbilical wound. It exists in the soil, and the disease 
prevails endemically in certain localities. It is common in certain parts 
of Long Island and New Jersey. Among the negroes in some parts of 
the South it has for many years occurred with great frequency. It is 
stated that on one of the islands of the Hebrides every fourth or fifth 
child dies of tetanus. In a single house in Copenhagen eighteen cases 
were observed. Tetanus presents no essential lesions. It is rare except 
where dirt and filth prevail; but these alone are not sufficient to produce 
the disease. It is rare in the tenements of New York. 

Symptoms. — These, as a rule, begin on the fifth or sixth day, or at 
the time of the separation of the cord. The first symptoms may not 
appear until the tenth or twelfth day, but rarely later than this. Gen- 
erally the first thing noticed is difficulty in nursing, which, on examina- 
tion, is found to be due to rigidity of the jaws (trismus). Nursing may 
be impossible on this account. The muscles of the jaw feel hard, the lips 
pout, and all the muscles of the face seem firm. Soon a slight stiffening 
of the body occurs, the child straightening the back as it lies upon the 
lap and continuing rigid for a moment or two. In the interval it is at 
first completely relaxed. These paroxysms soon increase in frequency 
until they may come on every few minutes, being excited by any move- 
ment of the body. The relaxation is then only partial, and the neck and 
extremities and sometimes nearly the whole body may become rigid and 
stiff as a piece of wood. The arms are extended, the thumbs adducted, 
and the hands clenched. The thighs and legs are extended, and no 
motion is possible at the hip or knee. The jaws can be separated slightly 
or not at all. The firm contractions of the facial muscles give a peculiar 
expression to the features. There is a low, whining cry. Swallowing is 
difficult, sometimes impossible. The pulse is rapid and soon becomes 
weak. The temperature at first is normal, but in the most acute cases 
rises rapidly to 104° or even 106° F. ; in the milder cases it does not go 
above 101° F. 

Death is due to exhaustion, to fixation of the respiratory muscles, or 
to spasm of the larynx. In the less severe cases all the symptoms are 
milder, and there may be intervals in which the rigidity is scarcely no- 
ticeable, so that respiration and deglutition may be carried on for some 



90 DISEASES OF THE NEWLY BORN. 

time. In cases which terminate in recovery the temperature is but 
slightly elevated. The tonic contractions gradually become less severe, 
and the paroxysms loss frequent. The children usually suffer for sev- 
eral weeks from the general symptoms of malnutrition, which are pro- 
portionate to the severity of the attack. Of eighty-eight fatal cases 
which arc reported by Stadtfeldt all but five died between the ages of 
six and ten days. The duration of the disease in the fatal cases is seldom 
more than forty-eight hours, often less than twenty-four hours; in 
those terminating in recovery, between one and three weeks. 

Prognosis. — Few diseases of infancy are more fatal than tetanus. 
Where it prevails endemieally it is regarded by the laity as so uniformly 
fatal that usually no physician is called. Scattered through medical lit- 
erature are quite a large number of isolated cases in which recovery has 
occurred. At the present time the proportion of fatal cases is probably be- 
tween ninety and ninety-five per cent. Sporadic cases more frequently 
recover than those occurring in districts where the disease is endemic. 
The later the development of the symptoms, the slower their course, and 
the lower the temperature the more likely is the case to recover. 

Prophylaxis. — A proper understanding of the nature of the disease 
has brought with it the means of rational prevention. The first essen- 
tial is obstetrical cleanliness, which must include scissors, hands, dress- 
ings, ligatures — in short, everything which comes in contact with the 
umbilical wound. In districts where tetanus is endemic, thorough asep- 
tic treatment of the umbilicus should be insisted upon, both at the first 
dressing and later, particularly at the time of the separation of the cord. 

Treatment. — All drugs whose physiological action is that of motor 
depressants of the spinal cord have a certain amount of value in tetanus. 
The most important ones are chloral and the bromides. Nearly all the 
reported cures have been by one of these drugs or a combination of 
them. The mistake usually made is in using too small doses. Enough 
to produce the physiological effects of the drug must be given. The 
initial dose should not be large, but it should be repeated until the full 
effects are obtained. Chloral, however, has been the drug most gen- 
erally relied upon. An hourly dose of one or two grains is usually 
required. If no effect is visible in ten or twelve hours the dose may be 
further increased, as the patient is in much greater danger from the 
disease than he can possibly be from the drug. Chloral may be given 
by the mouth or by the rectum, but must always be well diluted. The 
single case of recovery which I have seen was one treated by the bromide 
of potassium. This infant took eight grains every two hours for three 
days, afterward smaller doses. The child must at all times be kept as 
quiet as possible, without unnecessary handling or bathing. If nursing 
or feeding by the mouth is impossible, because the jaws cannot be sepa- 
rated, the child may be fed by a tube passed through the nose. This is 



FATTY DEGENERATION OF THE NEWLY BORN. 91 

greatly to be preferred to rectal alimentation. Drugs may be adminis- 
tered in the same way. 

The Antitoxine Treatment. — This is of especial value in prophylaxis. 
To be efficient as a curative measure it must be used early, for after the 
disease has developed it is very doubtful whether much can be accom- 
plished by its use ; but as it is harmless, it should be employed. 

EPIDEMIC HiEMOGLOBINURIA (WinckeVs Disease). 

The essential features of this disease are haemoglobinuria with icterus 
and cyanosis, this combination giving the skin a deeply bronzed hue 
(maladie bronzee). It is a rare disease, but has generally occurred epi- 
demically in institutions. It is usually fatal. It is, without doubt, in- 
fectious, but its cause has not been discovered. Although generally 
called by the name of Winckel, who in 1879 made a report upon an 
epidemic of twenty-three cases, the disease was quite well described by 
Charrin in 1873, with a report of fourteen cases, and observed by Bige- 
low, in Boston, in 1875. All the cases included in Winckel's report 
occurred in one institution, affecting one-fourth of the children born 
during the period. 

There is cyanosis, with a more or less intense icterus of the skin and 
internal organs. The umbilical vessels are usually normal. The kid- 
neys are swollen, show small haemorrhages into their substance, and 
under the microscope the straight tubes are seen to be filled with crys- 
tals of haemoglobin, but contain no blood-cells. The bladder frequently 
contains brownish, smoky urine. The spleen is swollen and filled with 
blood pigment, which is diffused throughout the cells of the pulp, and 
free in the blood-vessels. Punctate haemorrhages are seen in most of 
the other viscera. 

The symptoms usually begin from the fourth to the eighth day after 
birth, and are fulminating in character, seldom lasting more than two 
days. There are rapid pr.be and respiration, general restlessness, pros- 
tration, cyanosis, and general icterus, which may be intense. The tem- 
perature is normal or slightly elevated. There is rapid asthenia, often 
terminating in coma or convulsions. The urine is passed frequently, in 
small quantities. It is of a smoky colour, and contains haemoglobin 
in considerable quantity, renal epithelium, and sometimes granular casts 
and blood-cells, but does not contain bile pigment. Albumin is some- 
times present, but not in large quantity. 

Treatment is of little avail, since all severe cases die. 

FATTY DEGENERATION OF THE NEWLY BORN (BuhVs Disease). 

A disease has been described by the author whose name it bears, the 
essential nature and causation of which are unknown. It occurs as 



92 DISEASES OF THE NEWLY BORN. 

isolated cases, and is characterised by inflammatory changes leading to 
fatty degeneration in the viscera, especially the heart, liver, and kidneys; 

it seldom lasts more than two weeks, and is almost invariably fatal. 
Many o( the Lesions are similar to the ordinary post-mortem changes, 
and when found they should not be interpreted as pathological unless 
the autopsy is made within twelve hours after death. 

The clinical features of this disease, as described, resemble those of 
pyogenic infection; and since the observations were made before modern 
methods of bacteriological study, it is highly probable that Buhl's disease 
is merely a form of pyogenic infection in the newly born. 

PEMPHIGUS NEONATORUM— BULLOUS IMPETIGO. 

Pemphigus is a term which designates a lesion rather thaii a disease. 
By it is meant an eruption of bullae occurring usually upon a red base, 
the contents being in most cases clear serum. A condition somewhat 
resembling pemphigus sometimes follows the use in the newly born of 
too hot baths. Again, bullae are seen as one of the lesions of congenital 
syphilis; they are then usually present at birth or appear soon after. 
They are most frequently seen upon the palms and soles. Infants so 
affected are generally in wretched condition, and soon die. 

The onfy condition to which the term pemphigus neonatorum should 
be applied is quite different from both the preceding, and it has nothing 
in common with the pemphigus of later life. A better name is bullous 
impetigo, for its identity with impetigo contagiosa seen in older patients is 
now generally admitted. The disease is infectious, somewhat contagious, 
and occasionally occurs in small epidemics in institutions. Its spread 
in communities has been traced to midwives. The only important dif- 
ference between this disease and the common impetigo contagiosa seen 
in older children, is its severity and its association with visceral infec- 
tions. Most patients with bullous impetigo are delicate, neglected, and 
living in dirty surroundings; but not all are. I have seen it in robust 
infants who had received fairly good care. 

The greater number of cases studied thus far have shown the pres- 
ence in the blebs of the staphylococcus pyogenes aureus; less frequently 
the streptococcus has been the cause. The staphylococcus aureus was 
found in several typical cases occurring in my own hospital service. In 
one of these which came to autopsy, a general staphylococcus septicaemia 
was present. 

The clinical picture presented by pemphigus neonatorum is so strik- 
ing that it can scarcely be mistaken. The symptoms begin in most 
cases between the fourth and tenth day of life. The bullae first appear- 
ing are scattered and often not larger than one-fourth or one-half inch 
in diameter. They may be seen upon any part of the body, but are 



PEMPHIGUS NEONATORUM— BULLOUS IMPETIGO. 93 

especially frequent about the face, hands, and other exposed parts. They 
rupture or dry and form crusts without suppuration. The small bullae 
may gradually increase in size or several may coalesce until they cover 
an area two or three inches in diameter. As the disease progresses, new 
bullae may appear over almost any part of the body. The skin is at first 
slightly reddened, then an exudation of serum occurs beneath the epi- 
dermis which loosens and slides upon the true skin. After rupture of 
the large bullae, the epidermis at the margin forms a thin filmy border 
or hangs in shreds easily detached. The base of the large vesicles is 
a moist bright-red surface. When many have formed, the appearance 
closely resembles that seen after an extensive burn. 

The course of the local symptoms is at first slow ; then the bullae may 
spread with great rapidity and death occur in from twenty-four to forty- 
eight hours. In less severe cases the course is more prolonged, the blebs 
are smaller, and recovery may take place. 

The constitutional symptoms are at first wanting, but increase with 
the number and extent of the bullae. There may be a slight rise of 
temperature or it may be subnormal. There is progressive weakness and 



Fig. 16. — Pemphigus Neonatorum. Symptoms began on 13th day; death on 16th day of 
asthenia; temperature subnormal. The dark areas in the picture are entirely denuded 
of epidermis; they were formed by the coalescence of large bullae. 

great depression, much like that following a burn, and death occurs from 
exhaustion or from some visceral inflammation such as pneumonia or 
meningitis. 

It is important to distinguish pemphigus neonatorum from congenital 
syphilis. In syphilitic cases, the liver and spleen are usualty markedly 
enlarged, and other characteristic changes may be present in the nails, 
mucous membranes, or elsewhere. 

Treatment is of little avail in the most severe cases, when the bullae 
cover a considerable part of the surface of the body. The bulla? should 
be opened and drained, and the surfaces dressed with gauze covered with 
a two-per-cent ointment of white precipitate. There is little danger of 



94 DISEASES OF THE NEWLY HORN. 

mercurial poisoning. When dressings are changed the skin should be 
Bponged with a bichloride solution, 1-5,000 strength, or a one-per-cent 
solution o( ichthyol or permanganate o( potash. On account of the con- 
tagious nature of the disease eases occurring in institutions should be 

isolated. 



CHAPTER V. 
HEMORRHAGES. 

Hemorrhages are quite frequent during the first days of life, and 
are important not only from the fact that they are often the cause of 
death, but, when the brain is the seat, from their remote effects. There 
are several conditions in the newly born which predispose to bleeding — 
the extreme delicacy of the blood-vessels, and the great changes taking 
place in the blood itself and in the circulation in the transition from 
intra-uterine to extra-uterine life. Haemorrhages may complicate many 
of the diseases of the early days of life, such as syphilis or sepsis, or they 
may exist alone. - 

The cases may be divided into two groups : ( 1 ) Traumatic or Acci- 
dental Haemorrhages, which depend upon causes connected with delivery ; 
(2) Spontaneous Haemorrhages, or The Haemorrhagic Disease of the 
Newly Born. 

TRAUMATIC OR ACCIDENTAL HEMORRHAGES. 

These are mainly due to pressure in natural labour, or to means em- 
ployed in artificial delivery, but some of them may possibly result from 
injuries received before birth. They are more frequent in large children, 
in difficult labours, and where from any cause the body of the child has 
been subjected to undue pressure. 

Haematoma of the Sterno-Mastoid. — Haematoma of the sterno-mastoid 
muscle leads to the formation of a tumour in the belly of the muscle. 
It is a rather rare condition, usually noticed in the second or third week 
of life, and it disappears spontaneously, rarely causing any permanent 
deformity. The tumour varies from three quarters of an inch to one 
inch and a half in length, being about the size and shape of a pigeon's 
egg. It is movable, almost cartilaginous to the touch, and sometimes 
slightly tender. The situation of the tumour is usually about the centre 
of the muscle. There is no discoloration of the skin. 

In about two-thirds of the cases it occurs after breech presentations. 
It is much more frequent upon the right than upon the left side. In 
twenty-seven cases collected by Henoch the right side was involved in 
twenty-one and the left in only six cases. The explanation of this differ- 



TRAUMATIC OR ACCIDENTAL HEMORRHAGES. 95 

ence is to be found in the obstetrical position. Rarely, both sides may 
be involved. The head is usually slightly inclined toward the shoulder 
of the affected side and rotated toward the opposite side. The swelling 
slowly diminishes in size, and in most cases by the end of the third 
month has nearly or quite disappeared. Occasionally a slight torticollis 
remains for a longer time, but in the majority of cases the recovery is 
perfect. Hematoma of the sterno-mastoid is due to the twisting of the 
head during parturition. It is not an evidence of the employment of 
any improper force in delivery. The twisting of the head produces 
laceration of some of the blood-vessels of the muscle, and in some cases 
there is doubtless rupture of some of the fibres of the muscle itself. 
Following this there occurs a certain amount of inflammation of the 
muscle and its sheath. The tumour is due partly to blood-extravasation 
and partly to inflammatory products. In one or two recent cases in 
which the sheath of the muscle has been opened it has been found filled 
with blood. 

The condition requires no treatment. Operative interference is posi- 
tively contra-indicated. 

Cephalhematoma. — This is a tumour containing blood, situated upon 
the head, usually over one parietal bone, and tending to spontaneous 
disappearance by absorption. The source of the blood is the rupture of 
the small vessels of the pericranium. 

Etiology. — Cephalhematoma is sometimes due to a distinct trauma- 
tism like the application of forceps or to some other injury during 
labour. In the majority of cases, however, there is no evidence of such 
injury. Besides the conditions predisposing to all haemorrhages, there 
is the increased pressure in the blood-vessels of the head during delivery, 
especially when labour is prolonged or difficult ; there may be changes in 
the 'bone, such as an imperfect development of the external table; and, 
finally, there may be changes in the blood itself. Cephalhematoma is 
a comparatively rare condition, being present, according to the statis- 
tics of the Sloane Maternity Hospital, in 20 of 1,300 consecutive births, 
or 1.6 per cent. The condition is more common after first, or difficult 
labours, and in vertex presentations; occurring twice as often in males 
as in females, probably from the greater size of the head. 

Lesions. — In the 20 Sloane cases, the situation was over the right 
parietal bone in 12; over the left in 2; over both parietals in 4; over the 
occipital in 2. The location of the tumour seems to have a very close 
relation to the position of the head in the pelvis. ' In 8 of the right-sided 
cases the head was in the left occipito-anterior position. Of the cases 
with occipital tumours, both were breech presentations. Of the 16 
cases with a single tumour the labour was natural in 10, tedious in 4, and 
in 2 forceps were used. Of the 4 double cases, 2 were forceps deliveries. 

In rare cases triple tumours are met with, one over each parietal and 



96 



DISEASES OF THE NEWLY BORN. 




Fig. 17. — Triple Cephalhematoma. 
Infant seven days old. 



one over the occipital bone (Fig. 17 ). The attachment of the periosteum 
along the sutures usually Limits the tumour to the Burface of one hone. It 
never extends across the sutures or over the fontanel. Incases where there 

is a more definite injury, such 
as fro in forceps, the tumour 
may be present over any one 
of the cranial bones, but more 
frequently over the parietal. The 
seat of the haemorrhage is be- 
tween the periosteum and the 
cranium. The scalp shows punc- 
tate haemorrhages and sometimes 
infiltration with blood. In re- 
cent cases the blood is fluid ; 
later it is coagulated. The 
amount of extravasated blood is 
usually from half an ounce to 
an ounce. The cases following 
natural delivery are generally 
uncomplicated. The traumatic 
cases may be complicated by ex- 
travasations between the bone and the dura (internal cephalhaematoma), 
or by menigeal or cerebral haemorrhages. If there is a wound, infection 
may be followed by purulent meningitis and even by cerebral abscess. 
Symptoms. — The tumour is usually noticed from the first to the 
fourth day after birth, appearing as a slight prominence in one of 
the positions mentioned. Gradually increasing in size, it attains its 
maximum at the end of a week or ten days, and then slowly dimin- 
ishes. In size and shape the usual tumour may be compared to the 
bowl of a tablespoon. In marked cases it may be one-third the size of 
the child's head. To the touch it is soft, elastic, fluctuating, and irre- 
ducible. It does not increase with the cry or cough. There is no extra 
heat and no signs of inflammation. Usually the tumour does not pul- 
sate, although in rare instances pulsating cephalhaematomata have been 
seen. Very soon the tumour is surrounded b} T a marginal ridge. At 
first this is apparently from coagulation of blood, but later it may be 
bony. The prominent ridge with the soft centre gives a sensation some- 
what like that of a depressed fracture. Sometimes on pressure there is 
obtained a sort of parchment-crackling. This is generally found as the 
swelling is subsiding, and is sometimes clearly due to the formation 
of minute bony plates upon the inner surface of the periosteum. It 
may be found when there is nothing but thin coagula to explain it, In 
certain cases following severe traumatism, cephalhaematoma may be 
complicated with wounds of the scalp, fracture of the skull, and even 



TRAUMATIC OR ACCIDENTAL HEMORRHAGES. 97 

lacerations of the dura mater or the brain. In such cases the tumour 
may become inflamed, but in the spontaneous cases this is extremely rare. 
The usual signs of abscess develop, which may open externally or bur- 
row. Fortunately this termination is seldom seen. 

As a rule, without any interference, the uncomplicated cases go on 
to recovery. The complete disappearance of the tumour may be expected 
in from six weeks to three months, depending on its size; but a hard, 
uneven elevation may remain at its site for a longer time. The cases 
due to severe traumatism are more serious, the gravity depending not 
upon the cephalhematoma but upon the complicating lesions. 

Diagnosis. — Cephalhematoma may be confounded with encephalocele. 
This, however, occurs along the line of the sutures or at the fontanels, is 
partially reducible, pressure causes cerebral symptoms, and frequently 
the tumour increases with respiratory movements. Caput succedaneum 
often appears in the same place as a cephalhematoma and at the same 
time, but this is an cedematous, not a fluctuating tumour, and begins to 
disappear by the second or third day. From a depressed fracture of 
the skull, it is differentiated by the fact that in cephalhematoma there 
is a tumour and not a depression ; the prominent margin which is raised 
above the contour of the skull, is not osseous and the skull can be felt 
at the bottom of the centre of the tumour. 

Treatment. — The treatment in the uncomplicated cases is simply 
protective, all such cases tending to spontaneous recovery. No local or 
general treatment to promote absorption is required. The child should 
be so placed and so handled that no injury may be done to the affected 
part. Compresses are unnecessary. If complications exist, such as in- 
jury to the bones, dura, or brain, they are to be treated in accordance with 
general surgical principles. Operative interference is called for only 
when suppuration has occurred, or when there are brain symptoms which 
point to the existence of internal as well as external cephalhematoma. 

Visceral Haemorrhages. — While these are most frequent in large chil- 
dren and following difficult labours, they may occur in small children 
and where the labour has been easy and normal — their occurrence here 
being due to the feeble resistance of the blood-vessels. From one hun- 
dred and thirty autopsies upon still-born children or those dying soon 
after birth, Spencer concludes that intracranial hemorrhages are more 
frequent in head-forceps than in breech cases, and more frequent in 
breech than in natural vertex deliveries. Other visceral hemorrhages 
are much more frequent in breech cases. 

Not all visceral hemorrhages are to be classed as traumatic. They 
are often seen with the spontaneous hemorrhages from the skin or 
mucous membranes. When, however, they are single, they seem to be 
of traumatic rather than of pathological origin. 

The most important of the visceral hemorrhages are intracranial. 
8 



OS DISEASES OF THE NEWLY BORN. 

These are discussed in the chapter devoted to Birth Paralyses. Rarely 
there may be large haemorrhages into the Lung. Here the blood fills the 
air vesicles and the small bronchi, and coagula may be found even in the 
larger bronchi. A large part of a lobe or an entire lobe may be involved. 
On section the condition resembles atelectasis, and it may give the physi- 
cal signs o( consolidation. 

The abdominal viscera suffer more than those of the thorax because 
less protected against pressure. Small haemorrhages are not uncommon 
upon the surface of any of the viscera covered by peritonaeum. Intra- 
peritoneal haemorrhages are rare, but may be very extensive, amounting 
to one or two pints. Sometimes no ruptured vessel can be found. The 
haemorrhage may be primarily in the peritoneal cavity, or it may result 
from rupture of one of the viscera, especially the suprarenal capsule. It 
may be large enough to produce death from loss of blood. 

Small surface haemorrhages of the liver are not infrequent. Occa- 
sionally one of considerable size occurs separating the peritoneal cover- 
ing and forming a tumour generally upon the superior surface. Such 
laceration may be produced during labour, and a slow accumulation of 
blood may take place beneath the capsule, death resulting from rupture 
into the peritoneal cavity. Laceration of the capsule of the liver in a 
still-born infant has been reported. Of the large haemorrhages, those 
into the suprarenal capsules are perhaps the most frequent. The cap- 
sule may be distended to nearly the size of an orange, the kidney being 
surrounded by a mass of blood-clots. Blood may be extravasated into 
the retroperitoneal connective tissue, and rupture may take place into 
the peritoneal cavity. 

Except in the intracranial variety, visceral haemorrhages cause few 
symptoms, and in the great majority of eases the diagnosis is not made. 
Intrapulmonary haemorrhages have given rise to the signs of consolida- 
tion of the lung and even to haemoptysis. The abdominal haemorrhages 
are the most obscure. There may be a general abdominal distention 
with the usual symptoms of loss of blood, or there may be a circum- 
scribed swelling. In many cases nothing is noticed until a rupture of 
a subperitoneal haemorrhage takes place into the general peritoneal 
cavity, when there may be sudden collapse and death. 

The visceral haemorrhages are not amenable to treatment. The prog- 
nosis depends upon the size and position of the haemorrhage. In the cases 
of abdominal haemorrhage the diagnosis is extremely obscure and is rarely 
made during life. 

SPONTANEOUS HEMORRHAGES— THE HEMORRHAGIC DISEASE OF 
THE NEWLY BORN. 

A disposition to bleeding is seen with many diseases of the first few 
days of Life, especially those of an infectious character, like syphilis and 



THE HEMORRHAGIC DISEASE. 99 

pyaemia. With most of these, however, the haemorrhages are small, and 
the condition may he compared to the hemorrhagic tendency seen in 
certain forms of infection of later life, such as measles, smallpox, and 
malignant endocarditis. There is, however, a class of cases in which the 
haemorrhages are not associated with any other known process, and in 
which the escape of hlood from the small blood-vessels is the chief or 
essential symptom. In these cases the Weeding is much more extensive 
than in the others mentioned. These haemorrhages are characterised by 
the fact that they are spontaneous in origin, having no connection with 
delivery, they are multiple in location, and, while little influenced by 
treatment, they tend to cease spontaneously after quite a limited time. 
They are most often from the umbilicus, the mucous membranes of the 
stomach and intestines, or beneath the skin, but they may be from almost 
any mucous surface or into any organ of the body. 

Etiology. — These haemorrhages are not common, and are met with 
much more often in institutions than in private practice. In 5,225 births 
in the Boston Lying-in Asylum, Townsend reports 32 cases of haemor- 
rhage, or 0.6 per cent. In the Lying-in Asylum of Prague, Ritter ob- 
served 190 cases in 13,000 births, or 1.4 per cent. In the Foundling 
Asylum of Prague, Epstein reports haemorrhages in 8 per cent of 740 
infants. 

The condition is not a manifestation of haemophilia. Of 576 
bleeders collected by Grandidier, only 12 had a history of haemorrhage 
at the time of the falling off of the cord, and symptoms very rarely 
appeared before the end of the first year. Haemorrhages in the newly 
born are only slightly more frequent in males, while in haemophilia 
they predominate 13 to 1. The hemorrhagic disease of the newly born 
is self-limited, and runs a definite course to recovery or death. The 
tendency to bleed does not extend beyond a few weeks, and often lasts 
but a few days. Circumcision has been done within a few days after 
the cessation of the haemorrhages without any unusual bleeding. In a 
case under my observation with the most extensive subcutaneous haem- 
orrhages I have ever seen, all tendency to bleed had ceased before the 
separation of the cord, although there had previously been bleeding at 
the navel. The bleeding occurs with about equal frequency in feeble 
and in well-nourished infants. Syphilis is associated in but a small 
proportion of the cases. On the other hand of 132 cases of congenital 
syphilis observed by Mracek, only 14 per cent suffered from haemor- 
rhages. 

A more frequent association with sepsis has been noted. Of the 61 
cases observed by Epstein not less than 29. and of the 190 cases of Rit- 
ter, 24 were associated with sepsis. During one year there were 8 
marked cases of haemorrhage in the Xursery and Child's Hospital in 
about 225 deliveries. While more cases of sepsis occurred among the 



100 DISEASES OF THE NEWLY BORN. 

children during thai year than usual, it was striking that not one of 
those hemorrhagic cases gave any evidence of sepsis, and that none of 
the septic cases had bleeding. An epidemic of 10 eases of haemorrhages 
among 54 births at the Now York Infirmary for Women and Children 
was studied in L899 by Kilham and Mercelis. These all occurred in the 
(.(Huso of two months; the epidemic ceased as soon as the cases were 
properly isolated. 

The circumstances in which the hemorrhagic disease occurs point 
stronglv to an infectious origin. Quite a number of these cases have 
now been studied baeteriologically, but with no uniform results. 

While these haemorrhages are not traumatic, bleeding is exceedingly 
prone to occur in the skin over pressure points such as the back, the 
elbows, the occiput, and the sacrum. It is also common from the mu- 
cous membranes which are the seat of pathological processes, especially 
from the eyes, the nose, and the genitals. 

Lesions. — In very many of the cases the autopsy shows nothing except 
the haemorrhages in the various situations and the blanching of the 
organs due to the loss of blood. The haemorrhages of the brain are usu- 
ally meningeal and diffuse. They are considered more at length in the 
chapter upon Birth Paralyses. The pulmonary haemorrhages are usu- 
ally small and unimportant, and large haemorrhages into the pleura or 
pericardium are very rare. The stomach and intestines may contain 
considerable blood variously disorganised in the different parts of the 
canal, and there may be ecchymoses of the mucous membrane. In addi- 
tion, ulcers may be found in the stomach and duodenum. In twenty- 
four autopsies upon cases with haemorrhage from the stomach and intes- 
tines collected by Dusser, ulcers were found in the stomach in nine 
cases, and in the intestines in four. These ulcers are multiple, small, 
and usually superficial, but may extend to the muscular coat and may 
even perforate. The intestinal ulcers are found only in the duodenum 
and resemble those of the stomach. The cause of these ulcers is some- 
what obscure; some of them are undoubtedly dependent upon inflam- 
matory changes, probably of infectious origin; others have been com- 
pared to the peptic ulcers of later life, and are attributed to thrombi in 
the blood-vessels of the mucous membrane. These ulcers are found in 
but a small proportion of the cases in which bleeding occurs from the 
alimentary tract, and they may be wanting even where it has been very 
profuse. 

Small extravasations may be seen upon the surface or in the sub- 
stance of any of the abdominal organs. The changes found in the blood 
have not been uniform and have as yet been only imperfectly studied. 

Symptoms. — The onset is most frequently in the first week of life; 
very rarely after the twelfth day. The haemorrhages are usually mul- 
tiple. Their location in Hitter's 190 cases was as follows: Umbilicus, 



THE HEMORRHAGIC DISEASE. 101 

138 (umbilicus alone, 97); intestines, 39; mouth, 28; stomach, 
20; conjunctivae, 20; ears, 9. In Townsend's 50 cases: Intestines, 20; 
stomach, 14; mouth, 14; nose, 12; umbilicus, 18 (umbilicus alone, 3) ; 
subcutaneous ecchymoses, 21 ; abrasion of skin, 1 ; meninges, 4 ; cephal- 
hematoma, 3 ; abdomen, 2 ; pleura, lungs, and thymus, 1 each. 

In many cases nothing is noticed until the haemorrhage begins. The 
first bleeding noticed may be from the stomach, intestines, or any of the 
mucous surfaces, beneath the skin, or from the umbilicus. The amount 
of blood lost in most cases is not great, but there is a continuous oozing. 
The total haemorrhage may be only a few drachms or it may reach several 
ounces. The general condition is one of considerable prostration, often 
from the outset. In all cases there is rapid loss of weight. The tem- 
perature may be high, low, or subnormal. A marked elevation of 
temperature may depend not upon the haemorrhage but upon associated 
conditions. In a large number of the cases there is diarrhoea. 

The duration of the disease in cases which recover is usually but one 
or two days. In fatal cases it is rarely more than three days, and often 
less than one. Death may result from the gradual failure of all the vital 
forces or from rapid loss of blood. 

Umbilical Haemorrhage. — A slight oozing from the umbilicus not in- 
frequently occurs when the ligature has been improperly applied. This 
is generally controlled by simple measures. Spontaneous haemorrhage 
is quite different. It is rather later than bleeding from the mucous 
membranes, usually occurring between the fourth and the seventh day. 
There may be bleeding into the cord as well as from its free extremity. 
A slight stain upon the dressing is usually the first note of warning, 
but in exceptional circumstances a gush of blood is the first symptom. 
The haemorrhage may be temporarily arrested by various means, but it 
shows a strong tendency to recur in spite of everything which is done. 
The usual duration is two or three days. It has been known, however, 
to persist for twelve or fourteen days, and it may be fatal in less than 
twenty-four hours from the time it is noticed. 

Haemorrhage from the Stomach and Intestines. — Bleeding occurs 
much less frequently from the stomach than from the intestines. The 
latter is called melama. Gastro-enteric haemorrhages begin, in the great 
majority of cases, during the first three days of life. The blood vomited 
is usually in dark-brown masses, and not very abundant; more rarely 
it is bright red. The quantity varies from one drachm to half an ounce. 
Vomiting is liable to be excited by nursing. The blood discharged from 
the bowels is always dark coloured, usually intimately mixed with the 
stool, very rarely in clots. If in doubt between blood and meconium, 
one should look for the corpuscles with the microscope. When this is 
not conclusive on account of the disorganisation of the corpuscles, a 
chemical test for haemoglobin should be made. Concealed haemorrhage 



102 DISEASES OF THE NEWLY BORN. 

into the stomach may take place, which may even be sufficient to pro- 
duce death, no blood being vomited or passed by the bowels. In such 
cases the autopsy may reveal quite a large quantity of blood both in the 
stomach and intestines. 

Hemorrhage from the Mouth. — The quantity of blood is rarely large; 
but it is here that it is often first seen. Its source may be the mucous 
membrane of the mouth, pharynx, oesophagus, stomach, or bronchi. It 
may be associated with ulceration of the hard palate, with thrush, or with 
fissures of the lips. 

Hemorrhages from the nose are infrequent, and are more often due to 
syphilis than to other causes. These are rarely profuse, but are fre- 
quently repeated. 

Subcutaneous Hemorrhages. — These often appear in places exposed 
to pressure, such as the sacrum, heels, occiput, or back, but may occur 
anywhere. In some cases these haemorrhages are very extensive, as in 
one recently under observation, where nearly one-third of the thorax was 
covered. Where they occur alone or form the principal lesion, the prog- 
nosis is favourable. 

Hematuria. — The urine is not only stained with blood, but some- 
times contains clots. This haemorrhage may have its origin in the blad- 
der, urethra, or kidney. Blood coming from the kidney is sometimes 
due to the irritation of uric-acid infarctions, and may have nothing to 
do with the general haemorrhagic disease. 

Hemorrhage from the Conjunctiva. — The blood usually comes in 
drops from between the eyelids, chiefly from the tarsal surface. It is 
generally preceded by conjunctivitis. 

Hemorrhage from the Female Genitals. — This not infrequently oc- 
curs without haemorrhages elsewhere, and under such circumstances is 
rarely serious. Cullingsworth collected thirty-two cases in children 
under six weeks of age — no case having resulted fatally. These are not 
to be regarded as cases of precocious menstruation. 

Diagnosis. — This is generally easy, as the haemorrhages are usually 
multiple and some of them external. A slight haemorrhage from the 
intestine may be easily overlooked. Large haemorrhages into the in- 
ternal organs also are obscure and not often recognised. Spurious 
haemorrhages from the stomach may occur, blood being vomited which 
has been swallowed during birth or nursing. The source of bleeding 
may also be the mouth, nose, or pharynx, and sometimes blood is swal- 
lowed in large quantities and afterward vomited. These cavities should 
therefore always be examined, since local treatment may be efficacious. 
Syphilis should be suspected when the bleeding is chiefly nasal. 

Prognosis. — In all circumstances the haemorrhagic disease in the 
newly born has a bad prognosis. Of 709 cases collected by Townsend, 
the mortality was 79 per cent. In any single case the prognosis depends 



THE HEMORRHAGIC DISEASE. 103 

upon the extent and severity of the haemorrhage, upon the vigour of the 
child, and upon how well it can be nourished. No case should be looked 
upon as hopeless, for perfect recovery has repeatedly taken place where it 
seemed impossible. 

Treatment. — Local measures may be employed in all external haemor- 
rhages with some prospect of benefit. The bleeding points may be 
touched with persulphate of iron or with chromic acid fused upon a 
probe, or a solution of adrenalin chloride may be used. These measures 
may be employed alone or in combination with pressure. 

Although recoveries have been reported following the use of a great 
variety of remedies, it is by no means established that the result was due 
to the drugs employed. Many of the milder cases recover without any 
special treatment. On the whole, the medicinal treatment is very unsatis- 
factory. The drug which has been most in favour is adrenalin, which can 
be used internally in the form of suprarenal extract. I have myself seen 
one case in which decided benefit apparently followed its use in severe 
gastric haemorrhage. Two grains or more can be given every two hours. 
Gelatine has many advocates. It is used by subcutaneous injection. A 
two-per-cent solution which has been twice sterilised is employed, from 
40 to 50 c.c. being administered two or three times daily. Calcium 
lactate in some instances appears to exert a positive effect. It may be 
given in frequently repeated doses up to 20 or 30 grains a day. 

The latest addition to the treatment of this condition is the use 
subcutaneously of human blood serum. This was first suggested by J. 
E. Welch, of New York, who has tried it in seventeen cases. His results 
have been confirmed by others. Of the efficacy of this treatment there 
can be no longer any question. Whether all cases of haemorrhage of the 
newly born are due to the same cause and therefore amenable to the 
same treatment is not yet established. Whenever possible, therefore, 
injections of blood serum should be tried for these patients. The serum 
may be obtained from the blood of any healthy adult under sterile con- 
ditions; the quantity used should be from 40 to 50 c.c. injected three 
times a day. Larger doses may be used without danger. It should be 
repeated as long as any tendency to haemorrhage exists. Usually, how- 
ever, if it acts at all it does so promptly. In most patients all bleeding 
ceases in twenty-four hours after the first injection. 

The brilliant results which have followed transfusion as first prac- 
tised by Carrel should lead to its use in the event of failure by other 
means, whenever it is practicable to adopt it, no matter how grave the 
symptoms may be. The general treatment should have reference to 
maintaining the nutrition by careful feeding, judicious stimulation, and 
attention to the circulation, the body temperature, and the general con- 
dition of the child. 



104 DISEASES OF THE NEWLY BORN. 

CHAPTER VI. 
BIRTH PARALYSES. 

Birth paralyses are chiefly duo cither to pressure upon the child by 
the parts of the mother or to artificial means employed in delivery. 
They may be cerebral, spinal, or peripheral. 

Cerebral paralyses are in almost every instance due to meningeal 
haemorrhage, and accompanied by a certain amount of injury to the 
brain substance. Very infrequently they depend upon cerebral haemor- 
rhage. Laceration of the brain, or pressure from a depressed fracture. 

Spinal paralyses are extremely rare, and only a few examples are on 
record. They are due to laceration of, or haemorrhage into, the cord or 
its membranes. These lesions produce paraplegia, the exact distribution 
of which depends upon the point at which the cord is injured. 

Peripheral paralyses usually affect the face or the upper extremity. 
Paralysis of the face is due in most cases to the application of for- 
ceps. Paralysis of the upper extremity is most frequently of the " upper- 
arm type," and is known as Erb's paralysis. It usually follows extraction 
in breech presentations. Peripheral paralysis of the lower extremity 
is almost unknown. 

CEREBRAL PARALYSIS. 

Cerebral paralysis is often used synonymously with meningeal haemor- 
rhage. This lesion is not infrequent, and is of great importance not 
only from its immediate effects, but because upon it depend many of the 
cerebral paralyses seen in later life. According to Cruveilhier, at least 
one-third of the deaths of infants which occur during parturition are 
due to this cause. 

Etiology. — The same predisposing causes exist in the cases of menin- 
geal haemorrhages as in others occurring at this time. A small number 
of cases are associated with syphilis; others with pyogenic infection. In 
a few cases there is a history of an injury — usually a fall or blow upon 
the abdomen — during the last months of pregnancy. Meningeal haemor- 
rhage may occur as one of the lesions in the haemorrhagic disease of the 
newly born. The most important causes, however, are connected with 
parturition. These haemorrhages are essentially mechanical, and are 
favoured by everything which increases or prolongs pressure upon the 
head. The conditions with which they are associated are tedious labour, 
breech presentations with difficulty in extracting the head, instrumental 
deliveries, and premature births. The majority occur in first-born chil- 
dren. In many of the cases there is also a haemorrhage outside the skull. 

Lesions. — These haemorrhages are more common at the base than at 
the convexity, and at the posterior, than at the anterior part of the skull. 



PLATE II. 




Meningeal Hemorrhage in the Newly Born. 

From a patient in the Nursery and Child's Hospital, dying on the sixth day. 
Primary respirations poor ; child very dull and apathetic, refused to nurse ; once vom- 
ited blood and had an ecchymosis of the right conjunctiva. On the last day, high 
temperature (105° F.) and general convulsions. Some changed blood found in the 
stomach and intestines at the autopsy ; brain greatly congested, and at the base was 
the clot shown in the picture. 



CEREBRAL PARALYSIS. 105 

They are most frequently found over the cerebellum and the occipital 
lobes of the cerebrum. The entire extravasation is often beneath the ten- 
torium. The extent of the haemorrhage is exceedingly variable. There 
may be a single large clot at the convexity or at the base (Plate II), the 
haemorrhage may be limited to the convexity of one hemisphere, or it 
may cover nearly the entire surface of the brain. Diffuse haemorrhages 
are more common than a single circumscribed clot. In cases with ver- 
tex presentations the principal lesion is usually at the base, and often 
limited to that region. In breech cases it is more frequently at the 
convexity. The source of the blood may be a laceration of one of the 
sinuses of the dura mater caused by overlapping of the parietal bones. 
But more frequently the blood comes from one of the cerebral veins, 
or from the capillary vessels of the pia mater. In thirty-seven of Bed- 
nar's fifty-two cases, the extravasation was beneath the pia mater. In 
the remainder it was between the pia mater and the dura — i. e., in the 
arachnoid cavity. Haemorrhages between the dura and the skull may 
be said never to occur except when associated with fracture. If the 
child is still-born, or, if death has occurred on the first or second day, the 
blood is partly fluid and partly coagulated; later it is entirely coagu- 
lated and may have undergone partial absorption. The amount of ex- 
travasated blood varies between one drachm and four ounces, the average 
amount being about one ounce. The blood extends into the fissures 
between the convolutions and sometimes into the ventricles along the 
choroid plexus, although this is rare. In large haemorrhages the brain 
substance is softened and in places may be quite disintegrated ; but with 
small extravasations these changes are very slight and hard to demon- 
strate to the naked eye, though causing remote consequences often of a 
serious nature. In cases which survive for two or three weeks there is 
usually a certain amount of meningitis. The later changes — those of 
arrested development of the cortex and cerebral sclerosis — will be con- 
sidered in the chapter devoted to Cerebral Paralyses in the section on 
Diseases of the Nervous System. Haemorrhages into the membranes of 
the upper part of the cord are found in a large proportion of the fatal 
cases. Associated haemorrhages of the lungs and other organs are not 
uncommon. 

Symptoms. — If the haemorrhage is large, the child is usually still- 
born, although its movements may have been active up to the commence- 
ment of labour. When the haemorrhage is not so large as to be imme- 
diately fatal, the child may show no symptoms except dulness or stupor, 
with feeble or irregular respiration, death following within the first 
twenty-four hours. A large proportion of the cases are born asphyxiated, 
and frequently they are resuscitated only after considerable effort. They 
nurse feebly or not at all. Convulsions are common in cases which last 
for four or five days, and more with haemorrhages at the convexity than 



106 DISEASES OF THE NEWLY BORN. 

with those at the base. Opisthotonus is often present, also general rigid- 
ity of the extremities, clenching of the hands, and increased knee-jerks. 
Rarely there is complete relaxation of all the muscles. Sometimes there 
are automatic movements. The respiration is usually disturbed; in 
most cases it is slow and irregular. The pulse is feeble and usually 
slow. The pupils are more frequently contracted than dilated, and there 
may be oscillation of the eyeballs. There may be a slight exophthalmos. 
In large haemorrhages there is marked bulging of the fontanel, and often 
separation of the sutures. If the haemorrhage covers one hemisphere, 
there is complete hemiplegia of the opposite side. Small localised cor- 
tical haemorrhages may cause paralysis of the face, arm, or leg, according 
to the position of the lesion, or localised convulsions. In large haemor- 
rhages at the base convulsions are rare, and death occurs early, usually 
in the first two days. In extensive cortical haemorrhages convulsions and 
rigidity of the extremities are frequent, and life may be prolonged in- 
definitely. There is usually no fever, but exceptionally the temperature 
may be high. 

The majority of the fatal cases die within the first four days. In 
those lasting a longer time the symptoms are tonic spasm of the trunk, 
or of one or more of the extremities, with localised paralysis — mono- 
plegia, diplegia, or hemiplegia, according to the lesion — and localised 
or general convulsions often continuing for two or three weeks and 
gradually subsiding. In the mildest cases nothing abnormal may be 
noticed until the child is old enough to walk or talk. In those more 
severe there may be gradual and continuous improvement of the early 
symptoms, and the case may go on to apparent recovery, but usually 
there is some permanent damage to the brain. 

The main diagnostic s}^mptoms in recent cases are : bulging fontanel, 
slow pulse, stupor, rigidity, increased reflexes, convulsions, and paralysis, 
especially when localised, and opisthotonus. These vary with the extent 
and situation of the lesion. Lumbar puncture has very doubtful value. 

Prognosis. — A large haemorrhage at the base quickly causes death; 
if it is located at the convexity, although the child may survive, there is 
always serious damage to the brain. Even from small haemorrhages 
some permanent injury usually results, though the extent of this may 
not be evident for years. 

Treatment. — This is mainly prophylactic, the chief indication being 
to shorten tedious labours by the early use of the forceps. Where the 
haemorrhage has been attributed to the forceps, the damage has rather 
been the result of the long-continued pressure before they were used. 
Nothing can be done after delivery to limit the amount of the haemor- 
rhage, except to keep the child as quiet as possible. The removal of the 
clot by surgical operation has now been successfully accomplished by 
Cushing and others. With more accurate diagnosis there seems to be 



FACIAL PARALYSIS. 107 

no reason why a considerable number may not be saved. For the best 
results operation should be done as soon as possible. One great diffi- 
culty is that of early and accurate diagnosis. Paralysis whether local- 
ised or general is of greater value in diagnosis than are convulsions. 
The latter, however, are especially important when localised or contin- 
uous and threatening life. The operative risk, while considerable, is 
not to be measured against the permanent mental deficiency usually 
resulting in most of these children when nothing is done. Cases with 
similar symptoms are sometimes seen in which there is no extravasation 
of blood found at operation, but only intense congestion with an exces- 
sive serous exudate. In them also relief may follow operation. The 
hopeless outlook for such cases when not relieved, justifies the taking 
of great risks. 

FACIAL PARALYSIS. 

The usual cause of facial paralysis is the use of the forceps, but this 
does not explain all the cases. The etiology of those in which the for- 
ceps have not been used is still somewhat obscure. In peripheral facial 
palsy the nerve is pressed upon, either near its exit from the stylo-mas- 
toid foramen, or where it crosses the ramus of the jaw, at which point 
the parotid gland gives it but little protection in the newly born. If the 
lesion is in front of this point, any one of the terminal branches may 
be affected; most frequently it is the temporo-facial branch. As only 
one blade of the forceps commonly touches the face in this region, the 
paralysis is, as a rule, unilateral. 

Roulland has reported several cases not due to the forceps. In these 
the pressure is believed to have been produced by the promontory of the 
sacrum at the superior strait, or by the ischium at the inferior strait, as 
paralysis followed when the head was long arrested at one of these points. 
It was not seen with face or breech presentations. When facial paralysis 
is of central origin it depends generally upon a meningeal haemorrhage, 
and the arm and leg of the same side as the face are involved. It is, 
however, possible for a very small cortical haemorrhage to produce paral- 
ysis of the face only. 

In repose, the only symptom noticed may be that the eye remains open 
upon the affected side, owing to paralysis of the orbicularis palpebrarum. 
When the muscles are called into action, as in crying, the whole side of 
the face is seen to be affected. The paralysed side is smooth, full, and 
often oppears to be somewhat swollen. The mouth is drawn to the side 
not affected. In this paralysis, the tongue, of course, is not implicated. 
It is therefore rare that nursing is seriously interfered with. 1 If the 
paralysis is of central origin, only the lower half of the face is involved, 

1 In this connection it is to be remembered that the principal part in nursing is 
done by the tongue, and not by the lips. 



108 DISEASES OF THE NEWLY BORN. 

while in peripheral paralysis, as the trunk of the nerve is injured, the 
upper half of the face, including the orbicularis palpebrarum, is also 
affected. 

The paralysis is generally noticed on the first or second day of life, 
and does not increase in severity. Its course and termination depend 
upon the extent of the injury done to the nerve. Some idea of this may 
often be gained by the amount of injury to the soft parts, although this 
is not an infallible guide. In cases not due to the forceps, the paralysis 
is slight and disappears in a few days ; the great majority of the forceps 
cases follow the same favourable course, the paralysis gradually disap- 
pearing without treatment in about two weeks. In more serious cases 
it may last for months, or it may be permanent. The reaction of 
degeneration is present in these severe cases, and there may even be 
perceptible atrophy of the muscles. This symptom is fortunately ex- 
tremely rare. 

Treatment. — Nothing should be done for the first ten days except to 
protect the eye and keep it clean. If improvement has begun by the end 
of this time, the probabilities are that the case will require no treatment. 
If no improvement has taken place by the end of the third or fourth 
week, electricity should be used regularly and systematically. If the 
muscles respond to it, the faradic current may be employed; if not, 
galvanism should be used. The electrical treatment should be continued 
for several months, or until recovery has taken place. 

PARALYSIS OF THE UPPER EXTREMITY. 

When this is due to a peripheral lesion it probably never involves the 
entire arm, but affects only certain muscles or groups of muscles. Al- 
though commonly occurring after an artificial delivery, it may be seen in 
cases where the labour has terminated naturally. Roulland has reported 
a case in which deltoid paralysis, occurring in a large child, was attrib- 
uted to pressure upon the shoulder during labour. In vertex presenta- 
tions, paralysis is most frequently due to the forceps where one of the 
blades has extended down upon the neck, injuring the lower cervical 
nerves. It may be produced by traction with the finger in the axilla. 
Roulland reports a unique case of paralysis of both extremities, appar- 
ently due to the cord being very tightly wound around the neck. The 
great proportion of all cases of paralysis of the upper extremity follow 
extraction in breech presentations. The injury is usually inflicted In- 
fraction upon the shoulder in the delivery of the head, or in bringing 
down the arms when they are above the head. In the latter case the 
paralysis may be double and associated with fracture of the clavicle 
or humerus. In shoulder presentations, paralysis may be produced by 
traction upon the arm itself. The primary lesion consists of an actual 



PARALYSIS OF THE UPPER EXTREMITY. 



109 




rupture of nerve fibres and even of nerve trunks, probably with haemor- 
rhage into the nerve sheath. An inflammatory process follows as a result 
of which all these structures are fused together in one cicatricial mass. 

The most common form of peripheral paralysis is that known as the 
" upper-arm type/'' or Erb's paralysis, in which the injury is inflicted at 
the anterior border of the 
trapezius muscle at the 
lower part of the neck, usu- 
ally in such a position as 
to affect the fifth and sixth 
cervical nerves. The mus- 
cles paralysed are the del- 
toid, biceps, brachialis an- 
ticus, supinator longus, and 
sometimes the supra- and 
infra-spinatus. All these 
muscles may be involved, or 
only part of them, and in 
varying degrees. In case 
the injury is slight, the 
paralysis may not be noticed 
for some weeks. If severe, 
it is evident in the first 
few days. The arm hangs 

lifeless by the side ; it is rotated inward, the forearm pronatcd, the palm 
looking outward ( Fig. 18). The forearm and hand are not affected. In 
severe cases there may be anaesthesia of the outer surface of the arm, in 
the region supplied by the circumflex and external cutaneous nerves. 
This is rarely marked, and in its slighter degrees it is very difficult to 
determine. It is characteristic of this paralysis that the triceps is not 
affected, so that power to extend the forearm remains, although it cannot 
be flexed. Atrophy of the paralysed muscles occurs after a few weeks, 
but the muscles are so small and so covered with fat that it is rarely 
noticeable before the second year. It is most conspicuous in the deltoid. 
In all severe cases the reaction of degeneration is present. In some of 
the cases of long standing there occurs a shortening of the tendon of the 
subscapularis muscle, often associated with subluxation of the humerus. 
The paralysis may be complicated with fracture of the clavicle, the neck 
of the scapula, or the shaft of the humerus, or with epiphyseal separa- 
tum of its head. 

The prognosis depends upon the severity of the injury and also to 
some degree upon the time when treatment is begun. Many cases recover 
spontaneously in two or three months, improvement being observed within 
a few weeks, first in the biceps and last in the deltoid. Other cases 



Fig. 18. — Erb's Paralysis. 
Infant two months old. 



110 DISEASES OF THE NEWLY BORN. 

more severe in type recover after months as a result of systematic treat- 
ment by manipulation, massage, and electricity. The electrical reactions 
are of some value in prognosis. If the muscles respond to faradism, 
rapid improvement can generally be prophesied. If the reaction of de- 
generation is present, improvement will be slow and the paralysis is likely 
to be permanent. Permanent paralysis is most frequently of the deltoid. 

The diagnosis is usually not difficult, since the great majority of cases 
are of the " upper-arm type " with classical symptoms. Peripheral 
palsy of the arm can scarcely be confounded with that of cerebral ori- 
gin. If the lesion is central it is one of the rarest occurrences for the 
arm alone to be involved; either the leg or face, or both, are generally 
likewise affected. If the case does not come under observation until the 
child is a year old, it may be difficult, or without a good history it may 
be impossible to distinguish peripheral paralysis from that due to polio- 
myelitis. The peculiar group of muscles involved in Erb's paralysis is 
the only diagnostic point. 

In recent cases the disability resulting from the tenderness or pain of 
syphilitic epiphysitis may simulate paralysis, but there is lacking the 
characteristic position of the arm, and a careful examination discloses 
the fact that the paralysis is only apparent. This may affect both sides. 
Fracture of the clavicle or epiphyseal separation of the head of the hu- 
merus ma}' also be mistaken for paralysis. In cases of long standing, 
paralysis of the deltoid may resemble dislocation of the humerus. The 
reaction of degeneration differentiates paralysis from surgical injuries 
with similar deformities. 

The treatment consists in the use of massage, manipulation, and 
electricity, which should be begun at the end of the first month, and 
used regularly and systematically for months. If the muscles respond 
to faradism this may be employed, but in most severe cases they do not, 
and galvanism must be used, according to the rules laid down for facial 
paralysis. For cases which do not recover either spontaneously or under 
treatment, or show no marked improvement before nine months, opera- 
tion should be considered. This consists in dissecting out and suturing 
the nerve trunks whose continuity has been broken by the injury. A. S. 
Taylor, New York, from quite an extended experience, has reported 
marked improvement in some otherwise hopeless cases by tins operation. 



CHAPTER VII. 

TUMOURS OF THE UMBILICUS, MASTITIS, ETC. 

Granuloma. — This is nothing more than a mass of exuberant granu- 
lations at the umbilical stump. The mass is generally about the size of a 



TUMOURS OF THE UMBILICUS. 



Ill 



pea — sometimes larger — bleeds readily, and has a thin, purulent dis- 
charge. It is promptly cured by the application of any simple astringent ; 
powdered alum is probably the best. In case this is not successful, the 
granulations may be touched with nitrate of silver or snipped off with 
scissors. 

Adenoma, Mucous Polypus, or Diverticulum Tumour — Umbilical Fis- 
tula. — The first three terms are used synonymously to describe an um- 
bilical tumour covered with a mucous membrane which is similar in 
structure to that of the small intestine. It is usually associated with an 
umbilical fistula. This tumour is formed by a prolapse at the navel of 
the mucous membrane of Meckel's diverticulum. This diverticulum is 
the remains of the omphalo-mesenteric duct. When it is present in in- 
fants, it is found in various stages of development. Most frequently 
there is a blind pouch a few inches long given off from the lower part 
of the ileum. In other cases it may remain patent quite to the umbili- 
cus, causing a faecal fistula (Fig. 19, A). As the intestine below it is 
generally normal, this fistula may persist for months or even years, 
giving rise to no symptoms except a slight faecal discharge from the 
umbilicus. In certain eases intestinal worms have been discharged 
through it. It may close spontaneously or be closed by operation. 




Fig. 19. 



-Umbilical Fistula and Tumours Produced 
Diverticulum. (Barth.) 



by Prolapse of Meckel's 



A prolapse of the mucous membrane lining the diverticulum produces 
an umbilical tumour with a fistula at its summit (Fig. 19, B). This is 
the most common form. A cross-section shows under the microscope the 
structure of the intestinal mucous membrane both as an external cover- 
ing and lining of the fistulous tract. The prolapse may involve not only 
the mucous membrane but the entire intestinal wall. There then exists 
a conical tumour witli a fistula which lias but one external opening, but 
at a short distance from the surface it bifurcates, one branch leading 
upward and one downward (Fig. 19, C). A continuation of the pro- 
lapse gives a broad pedunculated tumour (Fig. 19, D), which may reach 
the size of a man's fist. Its covering is the same as in the other forms. 



112 DISEASES OF THE NEWLY BORN. 

It may contain several coils of intestine. In this form there are usu- 
ally two fistulous openings (a, b) which communicate with the intestine. 
In all of these cases the tumour is smooth, irreducible, of a rosy pink 
colour, and from its surface there oozes a mucous discharge. Microscop- 
ical examination shows the external covering to be the same in structure 
as the intestinal mucous membrane. These tumours are generally small, 
varying in size from a pea to a small cherry, but they may be very much 
larger. A faecal fistula usually, but not invariably, coexists. In the con- 
dition represented in Fig. 19, B, it is easy to see how an obliteration of 
the fistula may occur. The small tumours are readily cured by the liga- 
ture. The larger ones are usually associated with other serious mal- 
formations of the intestines, which make the outlook bad in almost every 
instance. 

UMBILICAL HERNIA. 

Hernia into the umbilical cord is a rare congenital condition of a 
serious nature. It is due to some foetal defect, and varies in size from 
a small protrusion to complete eventration in which nearly all the 
abdominal organs are outside the body. Many cases in which only intes- 
tinal coils are contained in the sac, though the tumour is quite large, 
are amenable to surgical treatment, which should be instituted at once. 
In the very large ones the prognosis is had. 

The common umbilical hernia is quite a different condition, and 
while a source of much annoyance it is rarely serious. It i- much more 
common in females than in males, and occurs especially in those who are 
poorly nourished and rachitic. The tumour is usually from one-fonrth 
to one-half an inch in diameter; it may. however, be very large, and may 
even become strangulated, when a surgical operation may become neces- 
sary. The ordinary cases, however, require only mechanical treatment. 
The most important thing is prevention. For this purpose it is neces- 
sary, after the cord has separated, to place a firm pad over the navel, and 
to use a snug abdominal hand for the first two or three months. After 
this period it is uncommon for hernia to develop. Tn cases coming under 
observation after the third or fourth month, the pad and abdominal 
bandage are inadequate, and other means must be employed to retain 
the hernia. The best of these consists in the use of two adhesive strips 
applied obliquely over the abdomen, crossing at the umbilicus, the skin 
along the median line being folded inward so as to overlap the tumour, 
this forming the retention pad. A simple method of retention is to place 
over the tumour a coin or button covered with kid and hold it in position 
by a strip of adhesive plaster ten or twelve inches long. One should be 
cautious about using the small conical pads frequently employed, as these 
tend to dilate the opening rather than to close it. If the skin is made 
absolutely clean and zinc-oxide plaster used, excoriations are rare. The 



MASTITIS. 113 

dressing should be changed every few days and worn for several months. 
After the first year all mechanical treatment is unsatisfactory. For the 
very small tumours it is really unnecessary to use any form of apparatus, 
since these cases ordinarily show little or no tendency to increase in size, 
and the retention apparatus causes more annoyance than the hernia. 
These small herniae sometimes disappear spontaneously during childhood, 
and rarely need be considered in children over seven years of age. Oper- 
ation- is seldom necessary. 

MASTITIS. 

According to Guillot, a certain amount of secretion in the breasts of 
the newly born is physiological. It is certainly very common. It is most 
abundant between the eighth and fifteenth days, but may continue in 
small quantities as late as the third month. It is seen with equal fre- 
quency in both sexes. The quantity of the secretion amounts in most 
cases only to a few drops; in some, however, as much as a drachm has 
been obtained. Chemical analysis has shown this secretion to be essen- 
tially the same as the adult milk — containing fat, sugar, protein, and 
salts. In gross appearance it resembles colostrum. The researches of 
Sinety have shown that the mammary gland of the newly born contains 
cul-de-sacs lined with secreting cells, resembling those of the adult. 
During the period of secretion the gland is slightly reddened, its vessels 
turgid, and all the signs of functional activity are present. This condi- 
tion in itself is of no practical importance, and in most cases, if left 
alone, the secretion ceases spontaneously after a week or ten days. It 
sometimes happens, however, that the presence of this secretion tempts 
the nurse or attendant to rub or squeeze the breast. Such manipulation 
occasionally leads to serious results by exciting a mastitis which may ter- 
minate in abscess. Mastitis is not a very rare condition, and although 
the inflammation is not usually severe, it may be serious and even fatal. 
The predisposing cause is the congestion which accompanies functional 
activity, usually in the second week. The exciting cause is most often 
some form of traumatism — undue pressure, the squeezing of the breasts, 
or rough handling by the nurse. Through abrasions or fissures thus pro- 
duced, micro-organisms find a ready entrance with the same result as in 
the adult. It seems possible that the germs may enter through the lac- 
tiferous ducts without any abrasion of the skin. Want of cleanliness is 
always a favourable condition for such infection. 

The symptoms of mastitis usually begin during the second week of 
life. There are redness, swelling, and the usual signs of inflammation. 
which may terminate in resolution or in suppuration. The process may 
be limited to the mammary region, or a diffuse phlegmonous inflamma- 
tion may be set up, and the case terminate fatally. In the female it is 



114 DISEASES OF THE NEWLY BORN. 

possible for the cicatrisation which follows such an inflammation to in- 
terfere with the subsequent development of the gland. The general 
symptoms are restlessness, loss of sleep, disinclination to nurse, and loss 
of weight. In cases of diffuse phlegmonous inflammation the general 
symptoms are those of pyogenic infection. 

Mastitis is usually due to want of cleanliness or traumatism; the 
parts should therefore be kept scrupulously clean, and on no account 
should squeezing of the breasts be permitted. They should be protected 
by a simple cotton pad. If acute inflammation develops, it should be 
treated in the beginning by hot applications. Should pus form, early 
incision with free drainage and general tonic and stimulant treatment 
are indicated. 

INTESTINAL OBSTRUCTION. 

The most frequent causes of intestinal obstruction in the newly born 
are malformations of the intestine ; rarely it may be due to pressure from 
tumours, or from a persistent omphalo-mesenteric duct or artery. The 
various pathological conditions present in intestinal malformations are 
considered in the chapter on Diseases of the Intestines. The most com- 
mon seat of obstruction is at the anus, the bowel being normally formed 
throughout, lacking only the external orifice. The next most frequent 
condition is obstruction in the rectum, which may be due either to a 
membranous septum in the gut, or to obliteration of the tube for some 
distance. These rectal obstructions are readily recognised. By the ex- 
amining finger or a bougie the lower limit of the obstruction can be made 
out, but there is no means by which the upper limit can be determined ex- 
cept by opening the abdomen. When the obstruction is above the rectum, 
localisation is more difficult; but the most frequent seat is the duodenum. 
Of 38 cases collected by Gaertner, the seat of obstruction was the duode- 
num in 19 cases, the jejunum in 3, the ileum in 11, the colon in 6, the 
ileum and colon in 1. There is often obstruction at more than one point. 

The symptoms vary with the seat and the degree of the obstruction. 
In atresia of the anus or rectum there is at first simply an absence of all 
discharges from the bowel. Later there is abdominal distention from 
dilatation of the sigmoid flexure and colon. After several days vomiting 
begins. If there is atresia of the duodenum or any part of the small 
intestine, vomiting begins early — usually by the second day of life — and 
it is persistent. Nothing is passed from the bowels after the first dark 
discharge of the contents of the colon, which is chiefly mucus. There is 
rapid asthenia, and death from inanition usually occurs in four or five 
days. The higher the obstruction the shorter the duration of life. If 
the condition is one of stenosis only, the symptoms are similar to those 
described but less severe, and life may be prolonged for several weeks, or 
even months. The constipation in these cases is not absolute. When the 



DIAPHRAGMATIC HERNIA. 



115 



cause of obstruction is external pressure, the symptoms do not always 
begin immediately after birth. I once saw a child in whom nothing 
abnormal was noticed for the first three weeks, but at the end of that 
time there developed all the signs of acute intestinal obstruction. Lapa- 
rotomy revealed a loop of intestine constricted by a tiny cord, which was 
probably the remains of the omphalo-mesenteric duct. 

Cases of imperforate anus and membranous septum in the rectum are 
readily relieved by proper surgical treatment. In the other varieties of 
obstruction, whether in the rectum, in the colon, or in the small intestine, 
although life may be prolonged by the formation of an artificial anus, 
the ultimate result is almost invariably fatal, death usually occurring 
from marasmus during the early weeks of life. 

DIAPHRAGMATIC HERNIA. 

This is due to a congenital deficiency in the diaphragm, which is 
usually on the left side. Of 118 cases collected by Livingston, 83 were 
on the left side, 18 on the right, 4 were central, 2 were double, in 1 the 
diaphragm was absent. With small openings only a single coil of in- 




Fig. 20, A. — Diaphragmatic Hernia of the 
Right Side, Posterior View. Child 
sixteen months old. 



Fig. 20, B. — The Same, Immediately af- 
ter Administration of Bismuth in Sus- 
pension. Stomach in the right thoracic 
cavity. 



testine, with large ones a considerable part of the abdominal contents, 
may be found in the thorax. This causes displacement of the heart, 
usually to the right side, prevents the full expansion of the left lung, 
and if the deformity occurs early in intra-uterine life the lung may 
remain rudimentary. If a large deficiency exists, infants may live but 
a few hours ; with smaller ones, life may be prolonged indefinitely. 



116 DISEASES OF THE NEWLY BORN. 

The symptoms noticed soon after birth are usually cyanosis, rapid 
respiration, a sunken abdomen, an overdistended chest and dyspnoea. 
Children often live but a few hours. In those who survive a longer time 
dyspnoea is generally the most prominent symptom. It may be constant, 
it may occur in severe paroxj^sms, or there may be attacks of cyanosis- 
often of great severity, these being produced by an accumulation of 
gas in the stomach or the thoracic part of the intestine. Other symptoms 
may at times suggest intestinal obstruction. The physical signs vary 
much from time to time. Sometimes those of pneumothorax are present ; 
at others there is so much dulness with the feeble respiratory sounds, 
as to suggest fluid. The signs are usually upon the left side, with dis- 
placement of the heart to the right. A positive diagnosis can be often 
made by means of the X-ray after the administration of bismuth. (See 
Figs. 20, A, and 20, B.) The condition is not amenable to treatment. 

CONGENITAL STRIDOR. 

This term has been given to a rather rare form of dyspnoea seen in 
very young infants, beginning usually in the first days of life. Respira- 
tion is noisy and inspiration is accompanied by a marked croaking, or 
crowing sound, and with recession of the soft parts of the chest wall, 
which, especially at times of excitement, may be very great, yet there 
is no cyanosis and no subjective distress. In spite of the apparent dif- 
ficulty of respiration the child seems comfortable. Expiration is usually 
easy and. voice and cry are normal. The stridor diminishes when the 
child is very quiet but usually does not quite disappear even in sleep. 

The symptoms begin in most cases immediately after birth or during 
the first week or ten days of life. They may increase for three or four 
weeks, then remain about stationary until the sixth or eighth month; 
after which with the growth of the larynx the dyspnoea and stridor 
steadily diminish. By the end of the second year it is usually gone or 
heard only on occasion. 

For our knowledge of this affection we are especially indebted to the 
observations of Thomson, of Edinburgh, who believes that the condition 
is primarily functional and due to a want of proper co-ordination of 
the respiratory muscles. Secondarily there is produced a folding of the 
epiglottis upon itself along the median line, so that its lateral borders 
approximate each other. In many of the cases reported, however, the 
change in the larjmx seems to be rather a malformation especially of the 
epiglottis, which greatly narrows the superior opening of the larynx. 
Congenital stridor is favoured by the soft collapsible character of the 
structures of the larynx in young infants and the strong suction force 
of inspiration. 

The prognosis in most of these cases is good, the chief dangers being 



SCLEREMA. 117 

from intercurrent disease or from broncho-pneumonia. Considerable de- 
formity of the thorax may be produced (pigeon breast) which may per- 
sist to later childhood. 

The diagnostic features of congenital stridor are the noisy respiration 
with marked inspiratory dyspnoea and crowing, with the absence of dis- 
tress or subjective symptoms of any kind. It seems to be more frequent 
in delicate children. Conditions with which it may be confounded are 
papilloma of the larynx, laryngismus stridulus, catarrhal croup, and 
laryngeal spasm associated with adenoids. The first three of these are 
excluded by the history and by the absence of changes in the voice ; 
the 'last one by the fact that the child is not a mouth breather, that the 
dyspnoea is not increased by closing the mouth. 

Congenital stridor is not amenable to special treatment. Should the 
dyspnoea reach an alarming degree tracheotomy may be performed. The 
indications are to maintain the child's general nutrition and to protect 
it, so far as possible, from diseases of the upper respiratory tract. 

SCLEREMA. 

Sclerema is a condition characterised by hardening of the skin and 
subcutaneous tissues. It may occur in circumscribed areas or extend 
over nearly the entire body. It affects infants who are very feeble and 
usually terminates fatally. Although sclerema is chiefly seen in the 
first days of life it is not limited to the newly born, but may occur at 
any time during the first few months. It is not to be confounded with 
oedema of the newly born, with which condition it is, however, sometimes 
associated. From published reports it appears to be of not very in- 
frequent occurrence in Europe, chiefly in large foundling asylums. In 
America, sclerema is not a common disease. In the newly born, sclerema 
affects those who are premature or very feeble, sometimes those who are 
syphilitic. Later it may follow any condition leading to extreme ex- 
haustion, especially the different forms of diarrhoeal disease. 

The first thing to attract attention is usually the induration of the 
skin. It is often seen first in the calves or the dorsum of the feet, 
sometimes first in the cheeks, but soon extends over the greater part of 
the body. It is especially marked in the cheeks, buttocks, thighs and 
back, and regions where adipose tissue is abundant. It may affect the 
body uniformly or in circumscribed areas. The skin may be smooth or 
it may appear somewhat lobulated. The colour is normal or slightly 
bluish, often tinged with yellow. The lips are blue, and the capillary 
circulation so feeble that after pressure upon the nails the blood returns 
slowly or not at all. The limbs are stiff and board-like. The skin is cold 
to the touch, and often the thermometer in the axilla will not rise above 
90° F. In one recorded case the axillary temperature was only 71° F. 



118 DISEASES OF THE NEWLY BORN. 

The general feeling of the body has been well likened to that of a half- 
frozen cadaver. The tongue and the mucous membrane of the mouth 
are cold; no radial pulse can be felt; the respiration is slow, irregular, 
embarrassed, and at times the movements of the thorax are scarcely 
perceptible. The cry is a feeble whine, scarcely audible. The duration 
of the disease is usually from three to four days. Death occurs slowly 
and quietly. If recovery takes place there is gradual improvement in 
the circulation and nutrition, and, later, a disappearance of the areas 
of induration. 

The causes of sclerema are general, the most important factors being 
loss of fluids, great feebleness with lowering of the body temperature, 
and, in consequence, hardening of the subcutaneous fat. There are no 
essential lesions in this disease. Atelectasis is often present, and may 
have something more than an accidental association, as incomplete 
aeration of the blood is no doubt a factor in the production of the symp- 
toms. Microscopical examination has shown the skin to be normal in 
typical cases. 

The prognosis is very bad, because of the grave conditions of which it 
is the expression, but it is not invariably fatal. In its milder forms, 
where treatment is begun early, recovery may take place. The diagnosis 
is to be made from oedema by the fact that there is no pitting upon 
pressure, by the rigidity of the body, and by the great reduction in the 
temperature. The most important thing in treatment is artificial heat; 
nothing but the incubator is efficient. In addition to this, care should 
be taken to promote the general nutrition by careful feeding and by 
all other means possible. 



INANITION FEVER. 

The term inanition fever is not altogether a satisfactory one; but, 
until these cases are better understood, it is adopted because it empha- 
sises the very close connection which exists between the rise of tempera- 
ture and the condition of inanition or starvation. Under this heading 
are included cases seen during the first five days of life — generally from 
the second to the fourth day — in which there is an elevation of tem- 
perature, apparently due to the fact that the infant gets very little, 
frequently nothing at all, from the breast at which it is being suckled. 
It is further characteristic of these cases that the temperature falls when 
the child is put upon a full breast, or when artificial feeding is begun, 
or even when water is administered, if freely given. Some have ascribed 
the symptoms to uric-acid infarction of the kidneys. 

So far as my knowledge goes, the first to call attention to this con- 
dition was McLane (New York), who in 1890 reported to one of the 
medical societies an extraordinary case of hyperpyrexia in a newly-born 



INANITION FEVER. 119 

child. The infant was found on the sixth day with a temperature of 
106° F., near which point it had remained for three days. The child 
was being suckled at a breast which was found to be absolutely dry. 
A wet-nurse was procured, the temperature fell to normal in a few 
hours, and the child, which when first seen was apparently in a hopeless 
condition, was soon perfectly well. 

Since that time very extensive observations, extending to upward of 
three thousand cases, have been made at the Sloane Maternity and Nurs- 
ery and Child's Hospitals, which have established the fact that a rise of 
temperature to 102° or even 10-1° F. is quite common in newly-born 
infants during the first few days. This fever is accompanied by no evi- 
dences of local disease, and ceases in nursing infants with the establish- 
ment of the free secretion of milk. The fall in temperature is often 
rapid, dropping to the normal in a few hours after having continued 
for three or four days, and in a large number of cases it does not rise 
again. 

The following case is a fairly typical one of the more severe form: 
The patient was the second child, the first having died at the age of 
ten days, from no disease, it was said, but simply from exhaustion. At 
birth the infant, a boy, weighed eight and a quarter pounds and was 
apparently vigorous. During the first forty-eight hours his loss in 
weight was five and a half ounces and his condition good. I saw him on 
the evening of the third day. In the preceding twenty-four hours he 
had lost eight ounces in weight, and the temperature had gradually 
risen, until at the time of my visit it was 102.8° F. The body was limp, 
the child making no resistance to examination. He cried with a feeble 
whine; the restlessness of the early part of the day having given place 
to complete apathy. The lips and skin were very dry, the fontanel 
sunken, the pulse weak. As the father, a physician, expressed it, " he 
had been wilting through the day like a flower in the sun." Although 
put to the breast regularly, the child had apparently obtained very little. 
It was, in fact, impossible to squeeze any milk from the mother's breasts. 
Water was freely given and a wet-nurse secured in a few hours. The 
first milk was taken from the wet-nurse at 11 P.M., and the temperature, 
which fell gradually during the night, was normal the next morning 
and did not rise again. (See chart, Fig. 21.) During the succeeding 
four days the child gained eighteen ounces in weight, and at the end 
of a week was as well as an average infant of his age. 

The symptoms are so uniform and so characteristic that they make 
for these cases of fever a class by themselves. The frequency with which 
this is seen is shown by the following statistics : Among 200 infants 
taken successively at the Nursery and Child's Hospital, 20 had fever 
during the first five days, reaching 101° F. or over, which was not ex- 
plained by ordinary causes and followed the course above described. In 



120 



DISEASES OF THE NEWLY BORN. 



102 : 



100 



1 2 3 i 5 6 7 S 




-r 


i 


I X 


p 


3 b 


3 : =E 


± :: 


5 :: 


t i 


-i i 


3 - 2^ 


^5^^^ 


L^_ J_ 



Fiq. 21. — Temperature Chart. 
Fever. 



Inanition 



500 successive children born at the Sloane Maternity Hospital, there 
were 135 with a similar fever. It was seen in vigorous infants as well 
as in those who were delicate. The usual duration of the fever was 

three days, the temperature gen- 
erally touching the highest point 
upon the third or fourth day of 
life. In about two-thirds of the 
cases the temperature did not rise 
above 102° F.; in 9 it was 101° 
F. or over, the highest recorded 
being 106° F. The fall was gen- 
erally quite abrupt, although not 
always so. Daily weighings, which 
were made in these cases, showed 
that the infants continued to lose 
weight while the fever continued, 
and that the loss almost invari- 
ably exceeded by several ounces 
that of the children who had no 
fever. The maximum loss noted 
was twenty -eight ounces. In quite 
a large number of cases it ex- 
ceeded twenty ounces. As a rule the infants began to gain in weight 
when the temperature remained at the normal point, but not until then. 
The symptoms presented by these infants were a hot, dry skin, 
marked restlessness, dry lips, and a disposition to suck vigorously any- 
thing within reach. With very high temperature there were considerable 
prostration and weakened pulse. In the less severe cases there were only 
crying and restlessness. The rapidity with which the symptoms dis- 
appeared when the children were wet-nursed or properly fed, was very 
striking. 

It is important that this fever should be recognised, because it gives 
at times the first warning of a condition which may prove fatal. The 
extra loss of ten or fifteen ounces in the first week, is a serious handicap 
to newly-born infants, the effect of which may last for several weeks. 
The temperature of every child should be taken during the first week. 
All the usual local causes of fever are first to be excluded by a physical 
examination. This fever can hardly be confounded with that due to 
pyogenic infection, which rarely begins before the fifth or sixth day. 

The treatment is simple, viz., to give water regularly every two hours, 
in quantities up to an ounce at a time if required by the thirst of the 
child. This should be done in every case where the temperature reaches 
101° F. When the temperature does not at once begin to fall, the infant 
should be put upon another breast or artificial feeding should be begun. 



INANITION FEVER. 121 

Examination of the breasts from which the child has been nursing will 
usually reveal the fact that the secretion of milk is very scanty and often 
entirely absent. 

Such a fever I have occasionally seen in older infants, usually in 
those who are nursing dry breasts or where fluid food and water have 
been withheld because of some. gastric disturbance. It yields as promptly 
to treatment as does the same condition in the newly born. 



SECTION II. 
NUTRITION. 

CHAPTER I. 
INTRODUCTORY. 

Nutrition in its broadest sense is the most important branch of 
paediatrics. In no other field and at no other time of life does prophy- 
laxis give such results as in the conditions of nutrition in infancy. The 
largest part of the immense mortality of the first year is traceable 
directly to disorders of nutrition. The importance of correct ideas re- 
garding this subject can hardly be overestimated. The problem is not 
simply to save life during the perilous first year, but to adopt those 
means which shall tend to healthy growth and normal development. 
The child must be fed so as to avoid not only the immediate dangers of 
acute indigestion, diarrhoea, and marasmus, but the more remote ones of 
chronic indigestion, rickets, scurvy, and general malnutrition, since 
these conditions are the most important predisposing causes of acute 
disease in early life. 

One of the difficulties has always been that temporary success may 
mean ultimate failure. If the injurious effects of improper feeding were 
immediately manifest, there would be very much less of it than exists 
at the present time. Many things are valuable as temporary foods, 
which when used permanently are injurious. No better illustration of 
this is seen than in the too exclusive use of the carbohydrate foods. In- 
fants fed upon many of the proprietary foods often grow very fat. and 
for the time appear to be properly nourished. The effect of the absence 
from the diet of some of those elements which are of vital importance 
may not be evident for months. The physiological laws regarding the 
requirements of the growing organism cannot be ignored without serious 
consequences, which will sooner or later be evident. Correct ideas of 
infant feeding are based upon a knowledge of these laws. An accurate 
understanding of fundamental principles is essential to success and the 
vast majority of failures may be ascribed to ignorance or disregard of 
them. 

122 



THE FOOD CONSTITUENTS. 123 



THE FOOD CONSTITUENTS AND THE PURPOSES THEY SUBSERVE 

IN NUTRITION. 

In infancy and childhood, as in adult life, the elements of the food 
are five in number : protein, fat, carbohydrates, mineral salts, and water. 
The forms in which they must be furnished to the child, and the relative 
quantities in which they are demanded, are different from those required 
by the adult. One reason for this difference is the delicate structure of 
the organs of digestion in infancy, and their inability to assimilate cer- 
tain forms of food. Again, provision must be made not only for the 
natural waste of the body, but for its rapid growth, nearly trebling in 
size, as it does, during the first twelve months. 

Protein. — Protein is essential to life, since it is the only kind of 
food which is capable of replacing the continuous nitrogenous waste of 
the cells of the body, upon which health depends. Protein is also in- 
dispensable for the growth of the cells of the body. In the adult only 
the requirements of repair are to be supplied. In the child a much 
larger amount is demanded to provide for growth. Protein should not 
be called upon to supply animal heat, although without the aid either 
of the fats or the carbohydrates, protein may sustain life for a consider- 
able time; but in so doing a great excess of such food is required. Such 
a diet taxes severely the digestive organs and those of elimination. 
When, however, fats and carbohydrates are added to the food, only one- 
half or one-third as much protein is required to replace the nitrogenous 
waste, as in the case of an exclusive protein diet. 

Of all the forms in which protein food may be furnished to the body, 
in proportion to its nitrogen content, milk taxes the digestive organs 
least. This fact is of the greatest importance and indicates the superior- 
ity of milk as a food, not only for the first year but throughout child- 
hood. The most easily digested protein is that of woman's milk. Regard- 
ing the protein of cow's milk there is no doubt that the view formerly 
held that it was very difficult of digestion was erroneous. On the 
contrary under most conditions it is digested and absorbed with facil- 
ity. During the first year milk furnishes all the protein that is needed 
for proper nutrition. During the second year meat, eggs, etc., may be 
advantageously added to the diet. 

The digestion of the protein is begun in the stomach but is prin- 
cipally carried on in the intestines. 

The protein molecule is a very complex one when compared with that 
of the fats or the carbohydrates. Growing out of this complexity of 
structure is the possibility of an immense number of side-products which 
may be formed by the splitting up of the protein molecule by digestive 
ferments, or by the numbers and varieties of bacteria found in the 
intestine. While the products of decomposition of the carbohydrates 



124 NUTRITION. 

are often irritating, those formed from the protein may at times be 
toxic and may be the cause of obscure and severe clinical conditions. 

The prolonged use of a diet in which the protein is insufficient in 
amount or of an unsuitable form, produces a certain definite group of 
symptoms which are not always referred to their proper cause. In 
infants the most striking are anaemia, poor circulation, feeble muscular 
power, disinclination to exertion, and various functional nervous dis- 
turbances. Such children are often very fat. The vegetable protein 
cannot permanently take the place of the animal protein in the food 
of young infants. 

Fats. — Fats are the most important source of animal heat, their 
caloric value being a little more than twice as great as that of the carbo- 
hydrates or the protein. They save nitrogenous waste. The fats and 
carbohydrates should be supplied in the food in such amount that the 
entire energy of the protein may be utilized for the growth and the 
nutrition of the cells of the body without being drawn upon to furnish 
animal heat. Fats increase the body weight. The large amount of fat 
stored up in the subcutaneous tissues in infancy is one of the best evi- 
dences of health. 

The fats supply important elements needed for the normal develop- 
ment of the nervous system. This fact is probably connected with the 
large amount of fat of various forms which the nerve structures con- 
tain. It is a familiar clinical fact that functional nervous disorders are 
exceedingly common as a result of the long-continued use of foods low 
in fat. Many such disturbances commonly seen with rickets are regarded 
by some as a consequence of fat-starvation. 

In the growth of bone the fats play an important role. The fatty 
acids formed in the intestine by the splitting up of the neutral fats of 
the food, combine with the insoluble salts of lime and magnesium and 
in this way, chiefly, these substances necessary for the growth of the 
skeleton are absorbed. Normal bony development, therefore, suffers if 
the food is low in fat. 

The unabsorbed fats have a distinct value in preserving the proper 
consistency of the faecal mass. While neither the protein of milk nor 
the milk sugar appears as such in the stools of the nursing infant, fat is 
abundant. It forms normally from twenty to thirty per cent of the dry 
substance of the stool. The amount furnished to the infant is, there- 
fore, considerably in excess of the needs of the body for nutrition. The 
use of this excess seems to be to increase the volume of the stool and to 
keep the mass so soft as to be easily expelled. 

The amount of fat required in infancy is relatively much greater 
than in adult life. A well-nourished nursing infant weighing fifteen 
pounds actually receives about one-half as much fat as is allowed in a 
ration for an adult doing moderate work, who weighs ten times as much. 



THE FOOD CONSTITUENTS. 125 

The form in which fat is supplied during the first year is the butter- 
fat of milk. There are marked differences in the fats of woman's and 
cow's milk, which to an important degree affect their digestibility. 
These are more fully considered later. Fats should be supplied liberally 
throughout childhood in the form of cream, eggs, butter, olive or cod- 
liver oil. 

While it is evident from the foregoing that the fat requirements of 
the young child are great, it must also be remembered that in certain 
conditions even the normal amount of fat is badly borne and may do 
positive harm. Fats do not readily form products injurious to the econ- 
omy as a consequence of imperfect digestion, but the amount given 
should be very greatly reduced in the following circumstances: (1) All 
wasting conditions depending upon disorders of digestion, whether due 
to functional derangement of the stomach, intestine, liver, or pancreas, 
or to chronic catarrhal inflammations of the stomach or intestine; (2) 
all acute disorders of digestion or acute inflammations of the stomach 
or intestines; (3) all febrile conditions, no matter from what cause; 
(4) during periods of very hot weather. A failure to regard these 
contraindications is a constant source of trouble in practice. 

In the conditions just enumerated the fats must largely be replaced 
by the carbohydrates, as these substances are capable for the time being 
of assuming the functions of the fats, and besides are easily digested and 
assimilated. Such substitution should not be continued too long, as 
serious results may follow. 

Carbohydrates. — Although these, like the fats, can not replace the 
nitrogenous waste of the body, they are important aids to the protein, 
and in this respect they are even more valuable than the fats. The 
carbohydrates are partly converted into fats, and may thus increase the 
body weight. They are capable of replacing the fat-waste of the body. 
They are one of the most important sources of animal heat. 

Carbohydrates arc the most abundant of the solid elements of the 
food, although they form a smaller percentage of the entire quantity 
of food in infancy than in adult life. The soluble carbohydrates which 
are used as foods for children are milk sugar, cane sugar, and maltose. 
Since all of these are converted by digestion into glucose they are to a 
certain degree interchangeable. In selecting milk sugar as the chief 
carbohydrate for the first year, we are following Nature, for this is 
what is furnished in the milk of all mammals. Milk sugar has a decided 
advantage in not fermenting with the common varieties of yeast present 
in the stomach, as do both maltose and cane sugar. Like the other 
sugars, however, milk sugar does readily undergo fermentation in the 
intestine by the action of bacteria. 

The ability of the young infant to digest starches is relatively feeble, 
although this power does exist to some degree from birth ; but the greater 



126 NUTRITION. 

part of the carbohydrates required should be furnished in the form of 
sugars. To infants of four months and over, starches may at times 
advantageously be added to the diet, and after eight months the quantity 
may be considerably increased. But in whatever form or quantity used 
thorough cooking is indispensable. Insufficient cooking is responsible 
for much of the starch indigestion seen in young children. 

The advantages of the carbohydrates as foods depend upon their easy 
digestibility. The transformation of any of the sugars into glucose is a 
relatively slight chemical change, when compared with that which is 
necessary in the fats or protein before they can be absorbed. 

The carbohydrates are at a great disadvantage on account of the readi- 
ness with which they undergo fermentation in different parts of the 
alimentary tract. To such fermentation are due many of the symptoms 
seen in the common functional disorders of digestion. 

A diet consisting too exclusively of carbohydrates leads often to a 
rapid increase in weight, but it is not accompanied by a proportionate 
increase in strength. Infants so fed have but little resistance, and many 
of them become rachitic. The easy digestion of foods consisting chiefly 
of soluble carbohydrates, such as condensed milk and the proprietary 
infant foods, and the rapidity with which children so fed gain in weight, 
lead to a great misapprehension in regard to their value as foods. The 
ultimate results of such one-sided feeding, if long continued, are almost 
invariably disastrous. 

In building up the cells of the body the protein is first in impor- 
tance, the carbohydrates second, and the fats third. In the production 
of animal heat the fats come first, the carbohydrates second ; practically 
the protein should never be called upon for this purpose. In a proper 
diet, all of these elements are represented. 

Mineral Salts. — These are relatively of greater importance in infancy 
than in later life, because of the rapid development of the skeleton dur- 
ing infancy and early childhood. The most important for this purpose 
are the phosphates of lime and magnesium. These are furnished in 
abundance both in woman's and cow's milk; but are deficient in prac- 
tically all the substitutes for milk. Salts are necessary for cell growth. 
They furnish the elements from which the mineral constituents of the 
blood and digestive fluids are formed, and facilitate absorption, excretion, 
and secretion. In fact, no function of the body is possible without the 
presence of salts in their proper proportions. 

Water. — The food of all young mammals consists of from eighty to 
ninety per cent of water. This is needed for the solution of certain parts 
of the food, such as the sugar, the salts, and some of the protein, and for 
the suspension of other protein and the emulsified fat. All the food 
is thus dissolved or very finely divided so as to be more readily acted upon 
by the delicate digestive organs of the infant. Water is needed also in 



WOMAN'S MILK. 127 

large quantities for the rapid elimination of the waste of the body. In 
proportion to its weight, an average infant during the first year requires 
about five times as much water as an adult. During the time when the 
child is upon an entirely fluid diet, the addition of much water other 
than that supplied by the food is unnecessary; but when the number of 
feedings becomes less frequent, and solid food is given in larger quanti- 
ties, water should be given freely between the feedings at all seasons, but 
especially in the summer. 

Caloric Values. — The different foodstuffs have different caloric values : 

One gramme of fat yields 9.3 calories 

" " " carbohydrate yields 4.1 " 

" protein yields 4.1 

It is important that these caloric values should be considered in the 
dietary of the child. The practical application of these facts is taken up 
in connection with the subject of infant feeding. 



CHAPTER II. 
THE INFANT'S DIETARY. 

WOMAN'S MILK. 

Woman's milk is the ideal infant-food. A thorough knowledge of 
its character, exact composition, and variations is indispensable, for upon 
this knowledge are based all our rules for the preparation of foods used 
as substitutes for woman's milk when this can not be obtained. 

Woman's milk is a secretion of the mammary glands and not a mere 
transudation from the blood-vessels ; although under abnormal conditions 
it may partake more of the character of a transudation than a secretion. 
A few drops may be squeezed from the breasts before parturition; gen- 
erally speaking, however, it is only present after delivery. During the 
first two days the secretion is scanty. Usually upon the third or fourth 
day it becomes well established, although it may be delayed several days 
longer and yet become abundant. During the period of lactation, milk 
is constantly formed in the mammary glands, but the process is more 
active while the child is at the breast. 

Physical Characters. — Woman's milk is of a bluish-white colour and 
quite sweet to the taste. When freshly drawn its reaction is ampho- 
teric to litmus, or slightly acid to phenolphthalein. The specific gravity 
varies between 1.026 and 1.036, the average being 1.031 at 60° F. On 
the addition of acetic acid only a slight coagulation is seen, this being 
in the form of small flocculi, and never in large masses as is the case 



128 



NUTRITION. 



in cow's milk. Microscopically, there are seen great numbers of fat- 
globules nearly uniform in size and some granular matter. Occasion- 
ally there are present epithelial cells from the milk-ducts or from the 
nipple. 

Colostrum. — The secretion of the first three or four days differs quite 
markedly from the later milk. To this the name colostrum has been 
given. It is of a deep yellow colour, which is chiefly due to the colos- 




Fig. 22, A. — Colostrum. (Funke.) 




Fig. 22, B. — Woman's Milk at a Late 
Period. (Funke.) 



trum-corpuscles. It is not so sweet as the later milk. It has a specific 
gravity of 1 . 030 to 1 . 040, a strongly alkaline reaction, and is coagulated 
into solid masses by heat, and sometimes coagulates spontaneously. It is 
very rich in protein and in salts. Microscopically the fat-globules are of 
unequal size, and there are present large numbers of granular bodies 
known as colostrum-corpuscles (Fig. 22, A). These are four or five 
times the size of the milk-globules (Fig. 22. B), and they are probably 
leucocytes in which are contained numerous fat granules. They are 
much larger than ordinary leucocytes and are nucleated. 



Composition of Colostrum. 

Protein 5.71 

Fat 2 . 04 

Sugar 3 . 74 

Salts 0.28 

Water 88.23 

100.00 

The colostrum-corpuscles are very abundant during the first few days, 
but under normal conditions they are not found after the tenth or 
twelfth day. 

Daily Quantity. — Exact information upon this point is difficult to 
obtain. There are recorded, however, extended observations made with 



WOMAN'S MILK. 



129 



great care upon eight cases, 1 from which some deductions may safely be 
drawn. All were healthy infants, nursing exclusively and gaining stead- 
ily in weight. 

From these observations, and others less extended, the average daily 



1 Haehner's cases (Jahrb. f. Kinderh., xv, 23; xxi, 314). Case I. Female; birth- 
weight 7 pounds 14 ounces (3,100 grammes). First week, lost 1£ ounce (45 grammes) ; 
after this gained steadily during the twenty-three weeks of observation; from second 
to ninth week, average weekly gain 8 ounces (241 grammes) ; from tenth to eighteenth 
week, average gain 4| ounces (138 grammes); from nineteenth to twenty-third week, 
average gain 4 ounces (130 grammes); weight at the end of twenty-third week, 14 
pounds (6,690 grammes). 

Case II. Male; birth-weight 61 pounds (2,950 grammes). Loss, first week, 3 
ounces (90 grammes); after this gained steadily during the eleven weeks of observa- 
tion; from second to eleventh week, average weekly gain 7i ounces (214 grammes); 
weight at end of eleventh week, 11 pounds 2 ounces (5,045 grammes). 

Case III. Female; birth-weight 3 pounds 9 ounces (1,620 grammes). Gain, first 
week, 1$ ounce (45 grammes) ; during the succeeding twenty-one weeks of observation, 
average weekly gain 5 ounces (141 grammes); weight at the end of twenty-second 
week, 10 pounds 3 ounces (4,620 grammes). 

Laure's case (These, Paris, 1889). Female; birth-weight 8 pounds 13 ounces 
(4,000 grammes) ; loss, first week, 8 ounces (225 grammes) ; after this gained steadily 
during the nine weeks of observation, on an average 9i ounces (268 grammes) weekly; 
at the end of ninth week, weight 13 pounds 3-J ounces (6,000 grammes). 

Ahlf eld's case (Deutsch. Ztschr. f. Prakt. Med., 1878). Birth-weight 7 pounds 14 
ounces (3,100 grammes). Observations continued from fourth to thirtieth week. 
During first ten weeks, average weekly gain 5$ ounces (161 grammes); from eleventh 
to twentieth week, 7i ounces (214 grammes); from twenty-first to thirtieth week, 6 
ounces (168 grammes); at the end of the thirtieth week, weight 18 pounds 9i ounces 
(8,435 grammes). 

Feer (Jahrb. f. Kinderh., xlii, 195). Three cases. 

In all these cases the amount of milk was determined by weighing the infant both 
before and after every nursing during the entire period of observation. The following 
table gives in a condensed form the daily quantity of milk in these cases: 



Time. 



1st day 

2d day 

3d day 

4th day 

5th day 

6th day 

7th day 

Average 2d week 

Average 3d week 

Average 4th week 

Average 5th week 

Average 6th week 

Average 7th week 

Average 8th week 

Average 9th week 

Average 10th to 13th week. 
Average 14th to 17th week . 
Average 18th to 23d week. . 
Average 24th to 30th week, 



Haehner's 


Haehner's 


Haehner's 


Laure's 


Ahlfeld's 


1st case. 


2d case. 


3d case. 


case. 


case. 


Grammes. 


Grammes. 


Grammes. 


Grammes. 


Grammes. 


20 


75 


20 






176 


135 


45 






265 


325 


70 


125 




420 


295 


99 


222 




360 


290 


124 


400 




374 


340 


136 


475 




423 


350 


156 


500 




497 


423 


229 


556 




550 


468 


314 


730 




594 


531 


379 


810 


576 


663 


561 


447 


944 


655 


740 


661, 


472 


978 


791 


• 880 


681 


525 


1,038 


811 


835 


730 


568 


1,024 


845 


766 


665 


584 


1,085 


810 


796 




600 




869 


807 




673 




983 


870 




709 




1,029 
1,145 



Feer's 
3 cases. 
Average. 

Grammes. 



256 

(average 
1st week) 



610 
667 
753 
802 
815 
820 
795 
845 
919 
1,002 



10 



130 NUTRITION. 

quantity of milk secreted under normal conditions of health may be 
assumed to be pretty nearly as follows : 

Approximately. 

At the end of the first week 10 to 16 oz. (300 to 500 grm.). 

During the second week 13 to 18 oz. (400 to 550 grm.). 

During the third week 14 to 24 oz. (430 to 720 grm.). 

During the fourth week 16 to 26 oz. (500 to 800 grm.). 

From the fifth to the thirteenth week. .20 to 34 oz. (600 to 1,030 grm.). 

From the fourth to the sixth month. . .24 to 38 oz. (720 to 1,150 grm.). 

From the sixth to the ninth month. .. .30 to 40 oz. (900 to 1,220 grm.). 

It will be noted that the amount increases very rapidly up to about 
the eighth week, and after this much more slowly. The amount of milk 
varies also with the demands of the child in a very striking way. 1 The 
quantities mentioned can not be taken as an absolute guide as to the 
amount of food to be given to bottle-fed infants. Breast milk contains 
an average of twelve per cent solids; while the modification of cow's 
milk best suited to the early months seldom has more than from nine 
to eleven per cent solids. For this period, therefore, somewhat larger 
quantities are needed than of breast milk. 

A comparison of the daily amount of milk taken with the weight of 
the child at the different periods, showed that both during the early and 
the later periods the larger children took not only more milk, but con- 
siderably more in proportion to their body weight than did the smaller 
ones. This harmonises with the common observation that small children 
are much more likely to be overfed than large ones. 

The average quantity taken at one nursing by five of the children 
previously mentioned was as follows : 

Approximately. 

During the first week £ to li oz. (18 to 45 grm.). 

During the second week 1 to 3 oz. (30 to 90 grm.). 

During the third week 1£ to 4 oz. (45 to 120 grm.). 

During the fourth week li to 4i oz. (45 to 140 grm.). 

From the fifth to the seventh week 2 to 5 oz. (64 to 150 grm.). 

From the eighth to the eleventh week 2-J to 5| oz. (75 to 160 grm.). 

During the fourth month 3 to 6 oz. (90 to 180 grm.). 

During the fifth month 3£ to 6£ oz. (110 to 200 grm.). 

During the sixth month 4 to 7 oz. (120 to 220 grm.). 

Between the limits mentioned the greater number of cases will un- 
doubtedly fall. The amount taken at one time is, however, modified 
by the frequency of nursing, and is therefore not so good a guide to the 
amount of food required, as is the quantity taken in twenty-four hours. 

1 There are a number of recorded instances in which the amount of milk secreted 
has been quite extraordinary — in some cases as much as four quarts daily. Lacta- 
tion in exceptional instances also is unduly prolonged. I know of one well authenti- 
cated American case in which it continued for seven years. Among the Japanese 
it is frequent for it to continue up to three or four years. Among the Hottentots 
and other savage races lactation may be prolonged until the sixth or seventh year. 



WOMAN'S MILK. 



131 



Composition. — Many of the older analyses of milk gave erroneous re- 
sults because of imperfect methods of examination. According to the 
more recent analyses of Pfeiffer, Koenig, Leeds, Harrington, Adriance, 
and others, the composition of human milk is as follows : 





Normal average. 


Common healthy variations. 


Fat 

Sugar 

Protein 

Salts 

Water 


Per cent. 

3.50 
7.00 
1.25 
0.20 

88.05 


Per cent. 

3.00to 5.00 
6.00 " 7.00 
1.00 " 2.25 
0.18 " 0.25 
89.82 " 85.50 




100.00 


100.00 100.00 



In the older analyses, the percentage of protein is almost invariably 
too high and the sugar too low. 

The milk varies in composition somewhat with the period of lacta- 
tion. That of the colostrum period is high in protein and salts and 
low in sugar. By the end of the second week all these elements have 
usually reached their normal averages. After this time until near the 
end of lactation the regular variations are slight. This is a point to be 
borne in mind in the selection of wet-nurses. 

Protein. — The important forms of protein are casein and lactalbumin ; 
several others, lactoglobulin, lactoprotein, and nuclein are also described. 
The casein is in suspension by virtue of the presence of lime phosphate in 
the milk, with which it is probably in combination. It coagulates only 
si ightly with rennet, while acetic acid produces a loose flocculent precipitate. 
The lactalbumin resembles the serum-albumin of the blood. Chemists are by 
DO means agreed in regard to the proportion of the different forms of pro- 
tein present in milk. Lactalbumin exists in woman's milk in much larger 
amount than in cow's milk, and it is more abundant than the casein, the 
proportion of the two being, according to Koenig, about as five to four. 

The total protein of normal milk is usually between one and two per 
cent. In abnormal specimens the variations are from 0.7 to 4.5 per 
cent. The protein is highest in the milk of the first few days ; after the 
first month it varies but little until toward the close of lactation, when 
the amount falls very markedly. 

Fat. — This exists in the form of minute globules, which are held in 
a state of permanent emulsion by the albuminous solution in which they 
are suspended. The fat of woman's milk is chiefly made up of the neu- 
tral fats — palmitine, stearine, and oleine ; the last mentioned predominat- 
ing. There are also small quantities of the fatty acids, but these are 
much less in amount than in cow's milk. In woman's milk the lower 
or volatile fatty acids are most abundant, while in cow's milk it is the 
higher fatty acids. Like the protein, the proportion of fat is subject 



132 



NUTRITION. 



1,010 



1,020 



1,040 — 



/ 




to wide variations, 3 . 5 per cent being taken as the normal average. In a 
series of thirty-four analyses made for me the fat varied between 1.12 
and 6 . 66 per cent. The highest percentage I have known was 10 . 91. In 
forty-three analyses by Leeds, the variations were between 2.11 and 6.89 
per cent. The proportion is very little affected by the period of lactation. 
Sugar. — The sugar is in solution. Its proportion is nearly constant. 
The ordinary variations are usually within the limits of 6 and 7 per 
cent. The sugar being so important as a heat-producing element, Nature 
has wisely provided that this shall be the most constant ingredient of 
the milk. The amount of sugar is smallest in the milk of the first 
week; after the first month, however, the variations are slight. 

Salts. — The average proportion of inorganic salts is 0.20 per cent, 
or a little more than one-fourth that of cow's milk. The proportion of 
the different salts is given in a subsequent chapter. 

With the exception of calcium phosphate nearly all the salts are in so- 
lution. The milk of the first few days is very rich in salts ; after the first 

month the variations are slight but show 
a gradual fall in the quantity present. 
The Examination of Milk. — The 
exact composition of human milk is 
to be determined only by a complete 
chemical analysis. There are, how- 
ever, many variations in composition 
which the physician may readily ascer- 
tain for himself by simple methods 
of examination. 

The quantity of milk secreted by 
the breasts may be estimated by the 
quantity which may be drawn by a 
breast-pump, although this is not a 
very reliable test. If the child nurses 
habitually thirty or forty minutes, the 
probabilities are very strong that the 
quantity of milk is small. If the 
breasts at nursing time are full, hard, 
and tense, the supply is probably 
abundant. If the breasts are soft and 
flabby, and appear to fill only while 
the child is nursing, it is almost cer- 
tain that the quantity is small. The 
most reliable of all tests is weighing 



\ 



a 



A B 

Fig. 23. — Apparatus for Examination 
of Woman's Milk. The author's lac- 
tometer and cream-gauge. 1 



1 The author's apparatus may be obtained from Eimer & Amend, Eighteenth 
Street and Third Avenue, New York. For a fuller discussion of the subject, see 
Archives of Paediatrics, March, 1893. 



WOMAN'S MILK. 



133 



the infant before and after nursing, upon an accurate pair of scales, suf- 
ficiently sensitive to indicate half-ounces. Two or three weighings will suf- 
fice to show conclusively whether an infant at three months, for instance, 
is getting habitually four or five, or only one or two ounces at a nursing. 

The reaction of woman's milk even when freshly drawn is rarely 
alkaline, being amphoteric to litmus, or slightly acid to phenolphthalein. 

The specific gravity may be taken with any small hydrometer gradu- 
ated from 1 .010 to 1.040 (Fig. 23, A). The specific gravity is lowered 
by the fat, but increased by the other solids. An ordinary urinometer 
will answer every purpose, the only difficulty being the quantity which 
is required to float the instrument. 

Microscopical Examination. — The microscope may reveal the pres- 
ence of fat globules, colostrum corpuscles, blood, pus, epithelium, and 
granular matter. Colostrum corpuscles are abnormal after the twelfth 
day; pus and blood are always abnormal. The presence of any of these 
elements necessitates the suspension of nursing, at least temporarily. 
But little importance can be attached to the size and appearance of the 
fat globules as affecting the nutritive properties of the milk. 

The Determination of Fat. — The simplest method is by the cream- 
gauge (Fig. 23. B). Its results are only approximate, but in most cases 
sufficiently accurate for clinical purposes. The tube is filled to the zero 
mark with fresh milk, which stands, corked, at room temperature for 
twenty-four hours, when the percentage of cream is read off. The ratio 
of this to the fat is approximately five to three; thus 5 per cent cream 
indicates 3 per cent fat, etc. 

For an accurate determination the best ready method is the Babcock 
test, which requires 20 c.c. of milk, or the 
modification by Lewi x of the Leffman and 
Beam test for cow's milk. This requires 
special tubes. 



® 



1 Lewi's method is as follows: 

(1) Place in the milk flask 2.92 c.c. of woman's 
milk measured in a special graduated pipette; 
(2) carefully rinse the pipette and add the same 
quantity of sulphuric acid C. P. of specific gravity 
1.830. The acid should be added slowly, and 
mixed with the milk by gently rotating the flask. 
The colour turns to a very dark brown from the oxi- 
dation of the sugar and protein; (3) now add 0.6 c.c. 
of a mixture of equal parts of fusel oil and strong hy- 
drochloric acid; (4) add sufficient of a mixture of 
the same sulphuric acid and water, equal parts, to 
bring the level of the fluid well up into the neck of 
the flask; (5) centrifuge for three or four minutes. 
The percentage of fat is now read off, each one- 
tenth gradation in the neck of the flask represent- 
ing 0.3 per cent of fat in the specimen of milk. 



R 




/A 



iii- 



Fig. 24 — Tubes for determining the 
Fat in Milk. A, Babcock's tube for 
cow's milk; B, Lewi's modification for 
woman's milk. 



134 



NUTRITION. 



Sugar. — The proportion of sugar is so nearly constant that it may be 
ignored in clinical examinations. 

Protein. — Clinical methods for the estimation of the protein are not 
altogether satisfactory. The one giving the best results is that in which 
the protein is precipitated by a solution of phosphotungstic and hydro- 
chloric acids in the Esbach tube, the percentages being read off after 
standing twenty-four hours. 1 We may also form an approximate idea 
of the protein from a knowledge of the specific gravity and the per- 
centage of fat, if we regard the sugar and salts as constant, or so nearly 
so as not to affect the specific gravity. We may thus determine 
whether it is greatly in excess or very low, which, after all, is the 
important thing. The specific gravity wall then vary directly with 
the proportion of protein, and inversely w T ith the proportion of fat, 
i. e., high protein, high specific gravity; high fat, low specific grav- 
ity. The application of this principle will be seen by reference to the 
accompanying table. 

Woman's Milk. 





Specific gravity 70° F. 


Cream — 24 hours. 


Protein (estimated). 


Average 


1.031 

1.028-1.029 

1.032 

Low (below 1.028) 
Low (below 1.028) 
High (above 1.032) 
High (above 1.032) 


7% 

8%-12% 

5%-6% 

High(above 10%) 

Low (below 5%) 

High 

Low 


1.5% 


Normal variations. . . 
Normal variations. . . 
Abnormal variations. 
Abnormal variations. 
Abnormal variations. 
Abnormal variations. 


Normal (rich milk) 

Normal (fair milk) 

Normal or slightly below 

Very low (very poor milk) 

Very high (very rich milk) 

Normal (or nearly so) 



Any specimen taken for examination should be either the mid- 
dle portion of the milk — i. e., after nursing two or three minutes — 
or, better, the entire quantity from one breast, since the composi- 
tion of the milk will differ very much according to the time when 
it is drawn. The first milk is slightly richer in protein and much 
poorer in fat. The last drawn from the breasts is low in protein 
and high in fat. The following analyses from Forster illustrate these 
differences : 





First portion. 


Second portion. 


Third portion. 


Fat 


Per cent. 

1.71 
1.13 


Per cent. 

2.77 
0.94 


Per cent. 
5.51 


Protein 


0.71 







Conditions Affecting the Composition of Woman's Milk. — The Age of 

the Nurse. — This has no constant influence. Other things being equal. 



1 For description see 
October, 1906. 



Boggs, Johns Hopkins Hospital Bulletin, No. 1S7, 



WOMAN'S MILK. 



135 



the milk of very young women, and also of those over thirty-five years 
of age, is likely to be lower in fat than that of women between twenty 
and thirty-five years. 

Number of Pregnancies. — Adriance found that the average milk of 
23 primiparae and 23 multiparas, both taken at the third month, showed 
the following differences: The milk of the primiparae was higher in fat 
(4.06 against 3.67) and in protein (1.61 against 1.35), but a little 
lower in sugar (6.52 against 6.85). 

Acute Illness. — In the majority of cases of acute illness of a minor 
character and of short duration there is no perceptible effect upon the 
milk. In the acute febrile diseases of a severe type the quantity of milk 
is reduced, the fat is low, and the protein is apt to be high. In septic 
conditions bacteria may appear in the milk. 

Menstruation. — The effect of this is exceedingly variable, depending 
much upon the individual and the ease of menstruation. 

The nature of the changes in milk sometimes produced by menstrua- 
tion is illustrated by the following case taken from Eotch : 



Fat . . . 
Sugar . 
Protein 

Salts. . 
Water . 



Second day of men- 
struation. Child's 
st (.(,18 loose. 



Per cent. 

1.37 
6.10 
2.78 
0.15 
89.60 



Seven days after 
menstruation. 
Bowels regular. 



Per cent. 

2.02 
6.55 
2.12 
0.15 
89.16 



Forty days later. 

Child gaining 

rapidly. 



Per cent. 

2.74 
6.35 
0.98 
0.14 
89.79 



From observations upon 685 cases, Meyer noted disturbances in the 
child in over one-half the number. My own experience accords rather 
with that of Pi'eiffer and Schlichter, who consider it quite exceptional 
for the child to be visibly affected. Schlichter made observations upon 
infants during 233 menstrual days, noting the condition of the stools 
and digestion botli before and after menstruation. In ninety per cent of 
the cases there was no perceptible influence. In only eight per cent 
were the stools bad, and in only three per cent was there disturbance of 
the stomach with vomiting. 

At the present time sufficient observations have not been made to 
show whether the' differences noted in the case cited above — low fat and 
high protein — are the rule where disturbances are produced during 
menstruation. Monti's examinations lead him to the conclusion that the 
fat is not constantly affected. It is safe to say that the changes are not 
uniform, and thai in very many cases none of importance are produced 
by menstruation. 

Diet. — The fat and the protein of the milk are much influenced by 
diet, the sugar but very little. The fat is increased by overfeeding es- 



136 



NUTRITION. 



pecially with fats and carbohydrates, with little or no exercise; it is 
reduced by stopping these articles and substituting vegetables and by 
increasing the amount of exercise. The protein is increased by over- 
feeding and also by too little exercise. Starvation lowers the fat and 
sometimes also the protein. All fluids tend to increase the quantity of 
milk. Alcohol in the form of malted drinks, and malt extracts increase 
the quantity of milk and the amount of fat. The effect of alcohol upon 
the protein is not constant, but it is usually increased. The following 
table gives the result of analyses of the milk of two women observed in 
the New York Infant Asylum before, while taking, and after taking an 
alcoholic extract of malt : 





I. 

Without malt. 


II. 

After taking 8 oz. malt 
daily for 10 days. 


III. 

No malt for 7 days. 


Case I: 

Fat 

Protein 


Per cent 

1.74 
1.93 
7.02 
0.20 

1.12 
1.57 
7.11 
0.19 


Per cent. 

3.83 
1.58 
7.43 
0.17 

2.75 
2.34 
6.77 
0.17 


Per cent. 
2.41 

2 95 


Sugar 


6 59 


Salts 


19 


Case II: 

Fat 


1 70 


Protein 

Sugar 


1.26 
6 04 


Salts 


0.18 



The child of Case I gained one ounce and a half during the four days 
preceding the first analysis; that of Case II did not gain at all. During 
the ten days while taking the malt, the first child gained twelve ounces, 
the second child eight ounces. During the seven days after the malt 
was discontinued, the first child gained eight ounces, the second child 
one ounce. There was a notable increase in the quantity of milk in both 
cases while taking the malt. 

The nursing woman should have a generous diet of simple food, and 
should drink largely of milk or gruels made with milk. The diet should 
be a varied one, not excessive in nitrogenous food nor in vegetables. All 
salads, pastry, and highly seasoned dishes should be avoided, not so 
much because they upset the child, although this may happen, as be- 
cause they are likely to disturb the digestion of the nurse. Nearly all 
the common vegetables and sweet fruits in season may be allowed in 
moderation. Strong tea and coffee should be prohibited, although weak 
tea or coffee may be allowed, each but once a day. Cocoa is not ob- 
jectionable. In addition to her regular meals the nurse should have 
milk or gruel at bedtime. The diet should in all cases be adapted to her 
digestion. The bowels should move daily, by the use of laxatives if 
necessary. Great harm often results from overfeeding with its conse- 
quent indigestion. Alcoholic beverages should be forbidden. 



WOMAN'S MILK. 137 

Drugs. — The elimination of drugs through the milk is somewhat un- 
certain and variable ; few of those popularly supposed to affect the child 
through the milk really do so. Given in full doses, belladonna regularly 
appears in the milk. Opium does not do so constantly; but when the 
milk is poor, enough may be excreted to produce serious symptoms. The 
iodides and bromides when long administered may be eliminated in 
sufficient quantity to produce their constitutional effects in the child. 
Mercury does not appear regularly, but only after prolonged use, and 
then in variable quantity. Most of the saline cathartics, arsenic, and the 
salicylates are occasionally found in the milk. Alcohol may seriously 
disturb the child if taken in considerable quantities by a nurse, although 
its elimination through the milk is doubtful. 

Pregnancy. — The milk of pregnant women is generally scanty and 
poor in quality, especially in fat. (See Weaning.) 

Bacteria. — Under normal conditions woman's milk may contain a 
few bacteria. They are chiefly cocci derived from the external milk ducts 
and are of no importance. In suppurative inflammation of the mam- 
mary gland, numerous bacteria may be found in the milk ; also in some 
cases of puerperal sepsis. Tubercle bacilli have been demonstrated by 
Roger and Gamier in the milk of a woman with advanced tuberculosis, 
but ordinarily they are not present unless the gland is the seat of the 
disease. 

The Elimination of Antitoxin and Other Protective Substances by the 
Milk. — The immunity of nursing infants to most of the contagious dis- 
eases has long been noted, but until recently little understood. Animal 
experiments have demonstrated the constant presence of diphtheria an- 
titoxin in the milk of immunised animals. The Widal reaction has been 
obtained with the milk of mothers suffering from typhoid and with the 
blood of their healthy nursing infants. 

Nervous Impressions. — The effect of the nervous condition of a 
woman upon her milk secretion is very striking, and much more im- 
portant than the diet. Both the quantity and the composition of the 
milk are markedly changed by many different nervous impressions. 
Fright, grief, passion, excessive sexual indulgence, or any great excite- 
ment may entirely arrest the secretion, or if not arrested the milk may 
be so altered in composition as to make the child acutely ill. Worry, 
anxiety, fatigue, intense or prolonged nervous strain may so alter the 
milk as to cause it to disagree with a child who had previously thrived 
well upon it, or they may greatly diminish and sometimes even arrest 
the secretion. Tt is the nervous condition of the mother more than 
anything else which determines her success or failure as a nurse. 
If a mother would nurse successfully, she must have plenty of rest 
and sleep, moderate exercise, keep her mind free from unnecessary 
worries, avoid social engagements, and lead a simple, regular, natural 



138 NUTRITION. 

life. Unless she can and will do this successful nursing can hardly 
be expected. 

The nature of the changes produced in milk by nervous disturbances 
in the mother are as yet little understood. Some infants are so pro- 
foundly affected as to suggest the development of toxic substances in the 
milk. The milk of the tired and worried mother is nearly always low 
in fat, while the protein is usually high, and possibly there are other 
changes as yet unknown. 

COW'S MILK. 

The only one of the lower animals whose milk is practically available 
for infant feeding is the cow. Cow's milk being our main reliance in 
the artificial feeding of infants and the staple food of nearly all young 
children, it follows that everything relating to its production and 
handling is important. The practising physician should therefore 
familiarise himself with the main facts regarding the production and 
handling of milk according to modern methods, since no one can do more 
than he to educate public opinion in these matters, and so to improve 
the milk supply of the community. Only an outline of the subject can 
be presented here. For more minute knowledge the reader is referred 
to special works upon the subject. 1 

The essential conditions to be fulfilled in cow's milk which is to 
be used as a food for infants and young children are : ( 1 ) Freshness ; 
(2) it should contain no preservatives; (3) it should be from healthy 
animals, free from tuberculosis or other taint; (4) it should be clean; 
(5) it should not be skimmed or otherwise falsified; (6) it should con- 
tain no pathogenic organisms ; ( 7 ) the number of other organisms should 
not be excessive. It is also desirable for purposes of infant feeding that 
the composition of the milk, particularly the percentage of fat, should 
be known, and that the milk should be as nearly uniform as possible from 
day to day and at different seasons of the year. Mixed or herd milk is 
therefore to be preferred to that from a single animal, since it is subject 
to fewer variations. The common varieties or " grade cows " should be 
chosen rather than highly bred animals, if for no other reason, because 
they are more hardy, less subject to disease, and less susceptible to other 
influences which might affect the milk. 

As ordinarily handled, milk should be used before it is twenty-four 
hours old; after this time changes occur very rapidly, and such milk 
can not in summer be used with safety for young children. Milk may 

1 Convenient works for a plrysician's use are Richmond's Dairy Chemistry; 
Aikman's Milk, Its Nature and Composition, Block, London; Russell's Outlines of 
Dairy Bacteriology; Belcher's Clean Milk, Hardy Publishing Co., New York; Pear- 
sons' Jensen's Milk Hygiene, Lippincott Co.; Milk and Its Relation to Public Health, 
Bulletin 56, U. S. Public Health and Marine-Hospital Service. 



COW'S MILK. 139 

be safe when more than twenty-four hours old provided special pre- 
cautions are taken regarding cleanliness in producing and handling it, 
and special care in keeping it constantly at a temperature below 50° F. 

Preservatives are very often added, particularly in hot weather, by 
unscrupulous dealers to retard the souring of milk, in order thereby to 
avoid the necessity and expense of proper icing. Formerly boric or sali- 
cylic acid was, and recently formaldehyd has been largely employed for 
this purpose. 

Micro-organisms in Milk. — Most of the common bacteria grow read- 
ily in milk, and the conditions under which it is produced and handled 
render it liable to contamination in many ways. 

1. Disease in the Cow. — From disease of the udder streptococci or 
other pyogenic germs may enter the milk in such numbers as to excite 
acute gastro-enteritis in a child. Other diseases which may be com- 
municated from the cow are tuberculosis, anthrax, and the foot-and- 
mouth disease. In the State of New York it is estimated that 7 per 
cent of the cows are tuberculous. Pearson and Ravenel estimate the 
proportion in Pennsylvania at 2 or 3 per cent, while Marshall states 
that from 10 to 25 per cent of the Eastern dairy cattle are tuberculous. 
The best veterinarians regard tuberculosis as steadily increasing among 
cattle in the United States, particularly in the Eastern States. Of the 
cattle slaughtered in London, 25 per cent are stated to be tuberculous. 
Unless the process is advanced or the udder is the seat of disease, very 
many tuberculous cows do not have tubercle bacilli in their milk. 
Nevertheless tubercle bacilli are frequently found in ordinary market 
milk. In 107 undetected specimens of milk sold from cans in New York 
City Hess found tubercle bacilli in 17, or 16 per cent. Rabinowitch and 
Kempner in 25 similar examinations in Berlin found tubercle bacilli in 
7, or 28 per cent. Macfadyen in London found, in 77 samples of milk, 
tubercle bacilli present in 17, or 22 per cent. These figures may be 
taken to represent average conditions in large cities. But the dangers 
from milk are not quite so great as would appear from these findings, 
for in many of the cases the number of bacilli is very small and only 
discovered by animal inoculations. 

For reasons given elsewhere (vide Tuberculosis), I can not believe 
the danger of acquiring tuberculosis through milk as great as many 
have represented. For the present milk must be regarded as one of the 
possible sources of tuberculous infection. The sale of milk from cows 
showing evidence of tuberculosis upon physical examination, and from 
those having tuberculosis of the udder should not be permitted. Whether 
we should go further and exclude also the milk of every cow which 
reacts to the tuberculin test is still an open question. 

2. Specific Pathogenic Organisms Accidentally Gaining Access to 
Milk. — The role of milk in the spread of infectious disease may be ap- 



140 NUTRITION. 

predated by the fact that in 1900 Kober collected records of 330 out- 
breaks which were traced to it. The most important disease communi- 
cated in this way is typhoid fever. In the reports of 195 epidemics 
collected, typhoid existed at the dairy in 148 instances; in 67 the milk 
was diluted with infected well-water; in 7 the cows probably waded in 
polluted water; in £4 cases the employees acted as nurses to typhoid 
patients, and in 10 they continued at work, although themselves suffering 
from the disease ; in one case it was found that the milk-pans were washed 
with cloths used about patients. 

Next to typhoid the disease most often spread thTough milk is scar- 
let fever. A very small percentage of the cases of scarlet fever, however, 
can be traced to contaminated milk; but the sudden and simultaneous 
development of a considerable number of cases of this disease in a com- 
munity should lead one to consider the milk supply as a possible cause. 
Of 99 epidemics of scarlet fever, there was disease at the farm or dairy 
in 68; in 17, employees were themselves affected, and in 10 they acted 
as nurses; in 6, persons connected with the dairy either lodged in or 
had visited infected houses; in 2 infection was brought by cans or 
bottles from the houses of patients; in 3 the milk was stored near or 
in the sick-room; in one case milk-utensils were wiped with an infected 
cloth. 

Very infrequently diphtheria has been spread through milk. Of 36 
outbreaks of diphtheria collected, there was disease at the farm or dairy 
in 13; in 3, employees themselves were ill. Twelve of the outbreaks 
included in this series, however, were of very doubtful character. Besides 
these diseases mentioned, cholera, dysentery, and certain forms of diar- 
rhceal diseases may probably be spread by milk. 

3. Other Bacteria Found in Milk. — These are chiefly derived from 
the dust of the stable, the hands and clothing of the milker, and from the 
dirt which falls from the udder, belly, and tail of the cow into the pail 
during milking; very many come from the cow's excreta. Freeman 
exposed a Petri gelatin-plate beneath a cow's udder for one minute dur- 
ing milking and obtained 4,450 colonies. The varieties of bacteria found 
in fresh milk are many and vary with locality. Toward the souring 
point the great majority are of two or three varieties only; fully 95 
per cent at that time belong to the lactic-acid-producing group. They 
cause the ordinary souring of milk by acting upon the milk sugar. Colon 
bacilli are very common. Other bacteria act upon the milk protein, 
inducing various putrefactive changes; and still others have a peptonis- 
ing power. 

Many of the bacteria are no doubt harmless. Others, while not, 
strictly speaking, pathogenic, when present in large numbers induce 
changes in milk that so impair its nutritive properties as to render it 
unfit for food, and in susceptible infants may cause serious illness. The 



COW'S MILK. 141 

effects of bacterial contamination of milk are considered in the intro- 
ductory chapter upon Diarrhceal Diseases. 

The Number of Bacteria in Milk. — This depends upon three condi- 
tions: (1) Cleanliness in handling; (2) temperature; (3) age of the 
milk. Hence the bacterial count becomes of the greatest value in fur- 
nishing information as to these matters, although of less importance in 
regard to the production of disease than the nature of the organisms 
present. The influence of the different factors may be illustrated by 
the following experiments made at the laboratory of the New York 
Health Department: A sample of milk taken under good conditions 
contained immediately after milking 300 bacteria in each drop. It was 
cooled to 45° F., and kept at this temperature. After twenty-four hours 
it contained in each drop only 200 bacteria ; after forty-eight hours, 900 ; 
and after seventy-two hours, 150,000. The milk curdled on the sixth 
day. Another sample, taken in a dirty barn, cooled and kept at 52° F., 
contained at first 2,000 bacteria in each drop; in twenty-four hours, 
6,000; in forty-eight hours, 245,000; in seventy-two hours, 16,500,000. 
The milk curdled on the fourth day. The influence of temperature alone 
upon the multiplication of bacteria in milk is well shown by the follow- 
ing experiment: Four samples of the same milk were kept at different 
temperatures for twenty-four hours and equal quantities were then 
plated; No. I was kept at 60° F. and showed 134,340 colonies; No. II 
was kept at 55° F. and showed 67,170; No. Ill was kept at 50° F. and 
showed 1,362; No. IV was kept at 45° F. and showed 448. 

The number of bacteria in bottled milk from single dairies usually 
ranges from 10,000 to 100,000 per cubic centimetre, according to the 
season. Milk from mixed dairies delivered in cases ranges from 100,000 
to 5,000,000, the latter number being often reached in very hot weather. 
There seems, however, to be little doubt that milk, in common with other 
animal fluids, possesses certain bactericidal properties which render it 
stable for a limited time, which are soon exhausted if the temperature is 
allowed to rise, but which assist materially in its preservation during the 
first twenty -four hours. 

The number of bacteria in cream is nearly always greater than in 
milk. Freeman's experiments with gravity cream showed that the bac- 
teria were 300 times as numerous in the cream as in the milk left be- 
hind, the bacteria being apparently carried up with the fat globules. 
This emphasises the necessity of the greatest care with reference to 
cream and indicates one great advantage of centrifugal cream, that it 
can be marketed at least twenty-four hours earlier than gravity cream. 

A Bacteriological Standard for Pure Milk. — There has been much 
discussion among different milk commissions regarding some such 
standard. One commission requires that the milk shall not have more 
than 10,000 bacteria in each cubic centimetre; another fixes the limit 



142 NUTRITION. 

at 30,000. Methods of cultivating and counting the bacteria of milk are 
by no means uniform, and it is often quite impossible to compare the 
figures of different observers, because not all the conditions were the 
same. Too much stress may be laid upon the mere number of bacteria ; 
their character must also be considered. A milk commission should be 
satisfied if all pathogenic organisms have been excluded and if the num- 
ber of other organisms is below 30,000 per cubic centimetre. There is 
no evidence that when these conditions have been fulfilled the results 
in infant feeding are any better with a milk containing 5,000 bacteria 
or less, than with one containing 30,000. Nor is there any proof that 
milk containing 30,000 bacteria per cubic centimetre is for this reason 
injurious. Emphasis should be placed rather upon the hygienic condi- 
tions under which the milk is produced and the exclusion of pathogenic 
organisms. A low bacterial count, if no preservatives have been used, 
may be taken as presumptive evidence at least that the milk is produced 
under hygienic conditions and carefully handled, and under such cir- 
cumstances the entrance of pathogenic germs is extremely improbable. 
It is quite possible to produce milk which is practically sterile; but 
the expense entailed is so great as to make the commercial produc- 
tion of such milk impracticable. For milk sold in cans 100,000 to 
the cubic centimetre may be considered good; for bottled milk any- 
thing under 30,000 is good, and an average under 10,000 is exceed- 
ingly good; the count in all cases being made at the time the milk is 
offered for sale. 

The reports made by the bacteriologist of one of the New York milk 
commissions show that by the most careful handling the number of bac- 
teria 1 can be kept at an average of less than 5,000 in each cubic centi- 
metre at the time when it is delivered. 

The Means of Excluding Pathogenic Bacteria, and of Checking the 
Spread of Contagious Diseases through Milk. — Eules are readily de- 
ducible from a study of the records of how milk has usually been infected. 

1. No person suffering from, or in contact with a person suffering 
from, a contagious disease should enter a dairy building or in any way 
come in contact with the milk or milk-utensils; especially should this 
rule be enforced in the case of diphtheria, scarlet and typhoid fevers. 

1 To accomplish such a result certain special precautions are observed; the most 
important are the following: The stables have cement floors to admit of ready flushing 
with a hose; no hay, straw, or fodder is kept in the stables; shavings are used for 
bedding; the cows are carefully groomed every day and not fed until after they are 
milked; a few minutes before milking the loose dirt is removed from the udders 
with a damp cloth. The milkers wear sterilised coats and caps, and wash their 
hands before milking each cow; all bottles, pails, etc., are sterilised with live steam, 
the pails just before using. The milk is immediately removed to the milk-house, 
where it is strained, mixed, cooled to 38° F., bottled and sealed — all within twenty 
minutes from the time it leaves the cows. 



COW'S MILK. 143 

Children, domestic animals, and, so far as possible, flies should be ex- 
cluded from rooms where milk is handled. 

2. Milk should not be handled in or near dwellings, privies, or sta- 
bles ; cans and pails should be washed only at the dairy, and after ordi- 
nary cleansing they should be washed in boiling water or sterilised with 
live steam. Especial attention should be given to milk-bottles which 
have been in infected rooms. The hands of the milker should invariably 
be carefully washed just before milking. 

3. Dairies should be subject to regular city or state inspection. Milk 
from cows showing physical evidence of tuberculosis should be excluded ; 
also that from animals which are in any way sick or are suffering from 
disease of the udder. Milk from apparently healthy animals who re- 
spond to the tuberculin test should not be used for food in a raw state. 

4. In any epidemic of contagious disease, the milk supply should 
be carefully investigated; and all cases of such diseases in the families 
of those who produce or handle the milk should be immediately re- 
ported and supervised by the authorities. 

Means of Reducing the Number and Lessening the Growth of Bac- 
teria in Milk. — A marked diminution in the number of germs present in 
milk, as it is now handled, may be brought about by attention to two 
conditions — cleanliness and temperature — and the results will be directly 
in proportion to the care bestowed upon them. 

Cleanliness must have reference, in the first place, to the cows them- 
selves. Since most of the germs in milk come from the cows, it is im- 
portant that the belly, udder, and tail should be cleansed before milking, 
to prevent droppings into the pail. The parts should be wiped with a 
damp cloth. Milking should be done out of doors or in a clean, special 
shed ; if in the stable, this should be clean. No dry fodder should be fed 
and no sweeping done, nor anything else to raise a dust, just before milk- 
ing. The milker's hands should be carefully washed and dried, not moist- 
ened with milk, as is sometimes done. Milk pails and cans should be 
washed, as stated above, and always dried upside down, remaining in this 
position until used. Pails with a small opening partially protected by 
a hood should be used to lessen the contamination with dirt from the 
cows during milking. All sieves and straining cloths should be steril- 
ised before each using. Milk should be bottled at the dairy, and so 
transported. Every time milk is handled, poured from one vessel into 
another, or in any way manipulated, the danger of contamination is 
increased. 

As to temperature, no point in the care of milk is more important 
than the rapid first cooling; as soon as possible after being drawn it 
should be cooled to at least 50° F. Unless the milk is taken at once 
to a milk-house and some of the special forms of cooling apparatus em- 
ployed, the cans should be immersed in spring water having a tempera- 



144 



NUTRITION. 



hire below 50° F. or in ice-water, and remain at least one hour. If a 
temperature of 50° F. is maintained during transportation, which is 
quite possible if cans and bottles are property iced, and during subse- 
quent storage, the growth of bacteria may be so retarded that milk may 
be a safe food even when forty-eight hours old. If the temperature is 
not kept as low as 50° F. this result can not be depended upon, and with 
every degree above that point the increase in bacterial growth is very 
marked. Since the number of bacteria increases so rapidly with the age 
of the milk after the first twenty-four hours, it is of the utmost impor- 
tance that milk be shipped as quickly as possible after it is collected. 

A provision of the Sanitary Code of New York City requires that no 
milk shall be sold having a temperature above 50° F. This ordinance 
has done more than anything else to improve the milk supply of the city, 
especially to insure proper icing during transportation. 

The desirable results indicated above are to be secured, in the first 
place, by educating the public to appreciate, and dealers to produce, a 
better and cleaner milk; secondly, by giving to the health authorities 
of city and state greater power than heretofore in the matter of milk 
inspection ; thirdly, by the formation of milk commissions, through which 
the physicians of a town or city may co-operate to secure adequate super- 
vision of at least a portion of the milk supply. 

Composition of Cow's Milk. — Except in the percentage of fat, the 
composition of mixed or herd rn^lk varies but little, whatever the breed. 
The fat is lowest in the Holsteins, and highest in the Jerseys. 



Composition of Cow's 


Milk. 1 






Jerseys. 


Holsteins. 


Average good 
herd milk. 


Fat 


5.61 
5.15 
3.91 
0.74 
84.59 


3.46 

4.84 
3.39 
0.74 

87.57 


4.00 


Sugar 


4.50 


Protein . . 


3.50 


Salts 


75 


Water 


87.25 






Total 


100.00 


100.00 


100.00 



1 In the table the figures for Jersey and Holstein herds are the averages given by the 
New York State Experiment Station. The legal requirements in New York and 
most of the States are, fat, 3 per cent; total solids, 12 per cent. 



The figures given for herd milk are a little lower for the protein 
and a little higher for the sugar than in the older analyses. It is with 
milk of such composition that the average physician has to do in infant 
feeding. In a poor milk the only important difference to be considered 
is that the fat is from 0.5 to 1 per cent lower than the averages given. 
In a rich Jersey milk the chief difference is that the fat is 1 to 1 . 5 per 
cent higher than the averages; there is also an increase in the protein 



COW'S MILK. 145 

and sugar which is less important, but should not be ignored. The vari- 
ations in the fat content of milk are those which are of most practical 
importance to the physician. As to the relative advantages of the dif- 
ferent breeds for this purpose, the difference does not seem great, pro- 
vided all are equally healthy. Jerseys and all highly bred animals are 
more prone to disease and minor disturbances than the hardier com- 
mon breeds. 

The Examination of Cow's Milk. — The application of heat often 
causes coagulation in milk which is near the souring point, and also 
in colostrum milk. Both are unfit for use. The normal reaction of 
cow's milk is amphoteric or slightly acid. If strongly acid it should 
not be used; if alkaline, it is pretty certain that something has been 
added to it. 

The specific gravity is from 1.028 to 1.033. If the milk has been 
falsified by the removal of cream, the specific gravity is raised; if adul- 
terated by the addition of water, the specific gravity is lowered. 

The best of all ready methods of determining fat are the Leffman 
and Beam and the Babcock tests. 1 By both, the fat is brought to the 
surface by the centrifuge after the addition of sulphuric acid and other 
reagents. These tests are similar, but differ in the reagents used. When 
carefully made they are very accurate. For institutions such an appa- 
ratus for determining the fat is indispensable; and the composition of 
the milk and the cream used can be determined each day. 

The cream-gauge may be used as for woman's milk, the 100 c.c. size to 
be preferred; but it is not to be relied upon unless the milk is put into 
the cylinder soon after it is drawn and cooled rapidly by being placed 
in ice-water. Under these conditions, if the reading is made at the end 
of eight or ten hours the percentage of cream to that of fat is about 
three to one. If the milk has been first cooled and afterward handled 
two or three times before the test is made, the cream does not rise regu- 
larly, and the above ratio is not maintained. 

A microscopical examination of milk is of considerable importance, 
and in cases where the character of the supply is questionable it may 
give valuable information. Both the cream and the sediment should be 
examined. Not much can be learned from a study of the fat globules, 
but among them may be found colostrum corpuscles, which are usually 
present for nearly a week after calving. The sediment is best studied 
after centrifuging. It should be examined for pus cells and blood, and 
stained for bacteria. A few leucocytes are almost invariably found in 
normal milk. Stokes and Wegefarth consider that an average of more 
than five in each field examined with an oil-immersion lens should be 

1 The apparatus can be obtained of D. H. Burrell & Co., Little Falls, N. Y. The 
one sold as the "Facile Junior" may be used for woman's milk, urine, and other 
fluids as well as for cow's milk, and is very convenient for physicians' use. Price, $10. 
11 



146 NUTRITION. 

regarded as abnormal, and such milk excluded. The most frequent 
source of pus cells in numbers is inflammation of the udder. Pus cells 
may be associated with a stringy mucus. Blood may also result from 
inflammation of the udder, sometimes from traumatism. 

When pus cells are present the specimen should be examined for bac- 
teria. Any of the ordinary pyogenic cocci may be found. Streptococci 
were found by Eastes in 75 per cent of 186 specimens examined, although 
in most of these the number was so small that no symptoms were pro- 
duced. He cites one instance where symptoms were caused. Woodward 
has reported a striking example where a family of five children were 
all made seriously ill with vomiting and collapse after taking milk 
which was found by him to contain large numbers of streptococci. The 
only certain way of demonstrating the presence of tubercle bacilli is by 
animal inoculation. 

Whenever pus cells, blood, or streptococci are at all numerous, the 
milk should be regarded as unfit for food and a thorough inspection of 
the herd should be made. 

The Differences between Cow's Milk and Woman's Milk. — Cow's milk 
is more opaque than woman's milk, although the latter may contain 
more fat. This opacity is due to the large proportion of calcium phos- 
phate with which the casein is combined. 

The reaction of cow's milk soon after it is drawn becomes acid. It 
is almost invariably so found unless some alkali has been added. Wom- 
an's milk is distinctly less acid. 

The specific gravity and total solids in the two milks are about the 
same. 

The sugar of both cow's and woman's milk is lactose in solution. 
The difference in amount is considerable. Cow's milk usually has 4.5 
per cent, while woman's milk usually has from 6 to 7 per cent. 

The greater part of the fat of. cow's milk is neutral fat, as in woman's 
milk; cow's milk, however, contains a much larger proportion of the 
lower or volatile fatty acids than does woman's milk. Woman's milk 
on the contrary contains more oleic acid. 

The protein of cow's milk is two and a half times as abundant as 
that of woman's milk, and it shows marked differences in character. 
Our knowledge of the protein both of cow's milk and woman's milk 
is still imperfect. The separation of the different forms of protein is 
difficult, and for this reason chemists are by no means agreed as to the 
proportions in which the different ones are present. It is well established 
that in woman's milk the soluble proteins — lactalbumin, etc., are in ex- 
cess of the insoluble casein, Koenig giving the proportion as 5 to 4; 
in cow's milk, on the other hand, the proportion of the soluble protein 
is much smaller than the insoluble, the latest writers giving the pro- 
portion as 1 to 3. 



COW'S MILK. 



147 



The casein * of cow's milk is readily coagulated by rennet and acids. 
The curd formed by the gastric juice is tough and firm and is more 
slowly dissolved by the action of the digestive fluids. The casein of 
woman's milk is not regularly coagulated by rennet, and only slightly 
and with difficulty by acids. The curd formed by the gastric juice is 
loose and flocculent, and is readily and completely dissolved. 

The inorganic salts in cow's milk are a little more than three times 
as abundant as in woman's milk. The most important differences in 
the composition of these salts are shown in the following analyses: 





Ash in 


100 Parts 


of 


Milk 


(Bunge). 






Cow's. 


Woman's. 


Potassium oxide 


.0703 
.0257 
.0343 
.0065 
.0006 
.0469 
.0445 


.1760 


Sodium oxide 


.1110 


Calcium oxide 


.1590 


Magnesium oxide 


0210 


Ferric oxide 


.0003 


Phosphoric acid 

Chlorine 


.1970 
.1690 














Total. 


.2288 


.7970 



Cow's milk contains relatively a much larger amount of calcium 
phosphate and a smaller amount of potassium salts and of iron. The 
ash does not accurately represent the mineral constituents of milk. 
About 8 per cent of the phosphoric acid of the ash, according to Rich- 
mond, is derived from the phosphorus of the casein; while the traces of 
sulphuric and carbonic acid found are not true mineral constituents of 
milk. Most of the more recent analyses show the presence of citric acid 
in both woman's and cow's milk. 

Cow's milk, always contains a large number of bacteria, which in- 
crease in proportion to the age of the milk; woman's milk is either 
sterile or contains but a few cocci from the milk ducts. 

Cream. — A great misapprehension exists as to its composition. It is 
often spoken of as if it were entirely different from milk. It should 
rather be regarded as milk which contains an excess of fat. 

Cream was formerly obtained by skimming — the gravity process — at 
present, almost entirely by the use of a centrifugal machine known as a 
separator. The latter process has the advantage in point of time, as 



1 By Haliburton and some other chemists the term caseinogen is given to this pro- 
tein as it exists in milk. When this is acted upon by rennet it splits up into two 
substances: One, the firm, insoluble coagulum to which only the term casein is applied; 
the other, a soluble protein which is known as whey-protein; this is present in but 
small amount. Those who use the term casein to designate the protein as it exists 
in milk refer to the curd formed by the action of rennet in the stomach as paracasein. 



148 



NUTRITION. 



centrifugal cream can be put upon the market from twenty-four to thirty- 
six hours earlier than gravity cream. 

The following table gives the composition of an average milk and of 
centrifugal cream of different densities removed from the same milk: 





Whole 
milk. 


Cream. 




I. 


II. 


III. 


IV. 


v. 


Fat 


4.00 
4.50 
3.50 
0.75 


8.00 
4.50 
3.40 
0.70 


12.00 
4.20 
3.30 
0.65 


16.00 
4.05 
3.20 
0.60 


20.00 
3.90 
3.05 
0.55 


40.00 


Sugar 


3.00 


Protein 


2.20 


Salts 


0.45 







The percentages of protein and sugar in the 8- and 12-per-cent 
cream are but little lower than in milk; in the very rich creams they 
are reduced by about one-third. 

It is unfortunate that no general standard exists as to what shall be 
sold as cream. In New York State the law provides that cream shall 
contain at least 18 per cent fat. Very rich, centrifugal cream has from 
35 to 40 per cent fat; the usual centrifugal cream has about 18 to 20 
per cent. Gravity cream has generally from 16 to 20 per cent fat. It 
is possible to obtain from milk laboratories cream of any desired fat 
percentage. 

None of the methods for determining the fat in milk is applicable 
to cream, except the Babcock test. 

Methods of Obtaining Milk Containing Various Proportions of Fat — 
Top-Milk, Skimmed Milk. — To secure a milk for infant feeding which is 
fresh and at the same time one which contains a larger proportion of 
fat than does whole milk, the practice has come into vogue of using from 
milk purchased and delivered in bottles, only a certain number of 
ounces removed from the top. To this the term " top-milk " has been 
given. Different percentages of fat, which are sufficiently accurate for 
practical purposes, may be obtained by varying the amount removed. 
Top-milk and thin cream are practically identical in composition. If 
cow's milk is put into bottles soon after it is drawn and rapidly cooled, 
it will be found that after four hours the upper fourth will contain 
nearly all the fat that will rise as cream, and the top-milk may then be 
removed. It is therefore unnecessary to allow the milk to stand for a 
longer time. Milk bottled at dairies and then transported should be 
allowed to stand after it is received for at least two hours before remov- 
ing the top-milk. This may be done with a siphon, spoon, or a small 
special dipper ; pouring off is not so accurate. 

Skimmed milk, or milk which contains a smaller proportion of fat 
than does whole milk, may be obtained from bottled milk by removing and 
rejecting a certain number of ounces from the top of the quart bottle and 



COW'S MILK. 149 

using only the remainder. The amount of cream removed will depend 
upon the proportion of fat desired in the skimmed milk. 

It is unnecessary in practice to have a top-milk which contains more 
than 7 per cent fat; while it is desirable at times to obtain milk which 
is practically fat-free. These two extremes and all intermediate pro- 
portions of fat may easily be obtained from bottled milk with approxi- 
mate accuracy by the method given below. The results will of course 
not be the same with all milks, but will vary considerably according as 
the supply is from a good herd of selected cattle of mixed breeds (aver- 
age 4 per cent fat), or from a Jersey of Alderney herd. It is therefore 
necessary for the physician to know with which one of these he is deal- 
ing, if the milk is to be used for infant feeding. 

If the original milk contains 4 per cent fat; If it contains 5 per cent fat; 

To obtain 7% fat, use upper 16 oz upper 20 oz. from 1 quart. 

" 6% " " " 20 " " 24" " " " 

" 5% " " " 24 " all. 

" " 4% " " all remainder after skimming 

off 2 oz. 
m u §% " " remainder after skimming off 2 oz .. remainder after skimming 

off 3 oz. 
u tt 2% " " " " " " 4 " ..remainder after skimming 

off 5 oz. 
" " 1% " " " " " " 8 " ..remainder after skimming 

off 8 oz. 

Fat-free milk can be obtained only by the removal of the cream by a 
separator. 

If the Jersey milk contains, as it often does, 5^ per cent of fat, 24 
ounces should be removed from a quart bottle to secure a 7-per-cent milk ; 
28 ounces to secure a 6-per-cent milk; and 3, 5, 8, and #10 ounces respec- 
tively to obtain a skimmed milk which has 4, 3, 2, and 1 per cent of fat. 

The physician should make or have made with the Babcock appa- 
ratus several fat tests of a given milk supply in order to obtain a basis 
upon which to make his calculations. In general it is wise for one who 
has much to do with infant feeding to have his patients take milk from 
the same supply to secure uniformity in his results. 

In or near large cities it is possible to obtain from milk laboratories 
milk with any desired percentage of fat. This of course greatly sim- 
plifies the whole matter. How top-milk and skimmed milk of different 
percentages are used will be considered in the chapter on Infant Feeding. 

Milk Sterilisation. — The term sterilisation is widely and rather 
loosely used to signify the heating of milk for the destruction of germs. 
It should, however, be borne in mind that none of the methods com- 
monly employed renders milk sterile in the bacteriological sense of the 
word. What is accomplished is the destruction of such pathogenic germs 
as may be present, and from 95 to 99 per cent of the other bacteria, so 



150 NUTRITION. 

as to retard for a considerable time the ordinary fermentative changes. 
The preservation of milk for infant feeding, by boiling it in small bottles, 
was advocated by Jacobi many years ago. 

The advantages of sterilising milk are obvious. When we consider 
the enormous number of bacteria present in cow's milk with the usual 
methods of handling, and that none of these, so far as is now known, 
are advantageous, but that they are frequently the cause of disease, it is 
not strange that after its introduction by Soxhlet in 1886 the practice 
of heating milk used for infant feeding was rapidly adopted all over the 
world. Following him, the earlier experiments in sterilisation were made 
at 212° F., usually continued for an hour and a half, and this tempera- 
ture is still largely employed on the Continent of Europe. Even this 
does not render milk safe for very long. Spores are not destroyed, and 
at ordinary room temperatures spore-bearing bacteria may soon develop 
in such numbers as to make the milk dangerous. Since some of these 
bacteria act upon the milk-protein and not upon the sugar, such milk 
may not be sour, and hence its danger may not be recognised. 

There are disadvantages in heating milk. The change in taste and 
the constipating effects of sterilised milk were soon noticed ; other altera- 
tions were not so evident and have more recently come to be appreciated, 
although many of these are not yet fully explained. Some of the lactose 
is converted into caramel, causing a slight change in colour; the lactal- 
bumin is partially coagulated, this beginning at 160° F. (70° C.) ; the 
casein is rendered less coagulable by rennet, and appears to be acted upon 
more slowly both by pepsin and trypsin; Rettger has shown that when 
milk is heated above 185° F. (85° C.) a volatile sulphide is liberated, 
conclusive evidence of a change in the protein; the organic phosphorus 
is changed into an inorganic phosphate ; the citric acid is partially pre- 
cipitated as calcium citrate, and some lime salts, which are usually solu- 
ble, are converted into insoluble compounds. Some changes also occur in 
the fat. Moreover, certain natural ferments in fresh milk, believed to be 
of value in digestion, are destroyed by heat. 

Many of these changes are but imperfectly understood, and some of 
them are doubtless without any injurious effect upon nutrition. There 
is, however, one important clinical reason for believing that the nutritive 
properties of milk are impaired by heating to 212° F. — viz., the occur- 
rence of scurvy in infants who are fed upon such milk for a long time. 
Of 379 cases of infantile scurvy brought together in the Report of the 
American Pediatric Society in 1898, sterilised milk was the previous 
diet in 107. At least a score of such cases have come under my own 
notice. Again and again cases of scurvy have been cured by simply ceas- 
ing to sterilise the milk. 

Heating at Lower Temperatures — Pasteurising Milk. — To obviate the 
disadvantages above referred to, the practice has come largely into use 



COW'S MILK. 151 

in America of employing much lower temperatures for milk sterilisa- 
tion, owing chiefly to the work of Freeman (New York) and Eussell 
(Wisconsin). 

At first 167° F. (75° C.) was used; subsequently, however, a lower 
temperature was found sufficient, and 150° to 155° F. (65° to 68° C.) 
are the temperatures which are now generally employed. These tempera- 
tures are maintained from twenty to thirty minutes. This is sufficient 
to kill the bacilli of tuberculosis, diphtheria, and typhoid fever, and 
from 98 to 99.8 per cent of all other bacteria in milk. Nearly 
all of the objectionable changes produced in sterilised milk are avoided 
when the temperature is raised only to 150° F. (65° C), while it accom- 
plishes the purpose for which milk is heated. The advantages of this 
form of heating are therefore obvious. But spores are not destroyed, 
and such milk requires special handling. It should always be rapidly 
cooled and kept at a low temperature. Pasteurised milk should be used 
within a few hours after heating; no attempt should be made to keep it 
more than twenty- four hours, even upon ice. 1 

Pasteurisation vs. Sterilisation. — From what has already been said 
it would appear that the argument is altogether in favour of pasteurisa- 
tion. The lowest temperature and the shortest time that will surely 
destroy the objectionable bacteria in milk would seem to merit general 

1 Quite distinct from the process just described is that known as commercial 
pasteurisation. In this, by passing milk through hot pipes, it is heated to tempera- 
tures ranging from 140° F. for several minutes to 160° F. for a very brief period, 
usually for 5 to 30 seconds. Such heating destroys from 90 to 99 per cent of the 
bacteria ordinarily found in milk. According to the experiments made in the labora- 
tory of the New York Health Department, a temperature of 160° F. maintained for 
30 seconds under usual conditions kills typhoid, diphtheria, and colon bacilli. In a 
small percentage of experiments about 1 in 100,000 of these bacteria withstood this 
exposure. 

By this treatment (160° F. for 30 seconds) the great majority of tubercle bacilli, 
which are the most resistant of the bacteria exciting disease that are found in milk, 
are either killed or so injured that they can not infect. On the average about one- 
tenth of 1 per cent survive; 160° F. for one minute usually kills all. 

The pasteurised milk of commerce which is extensively sold in many large cities is 
chiefly milk that has been heated for from 5 to 30 seconds in the manner described. 
The destruction of pathogenic organisms is a great advantage. The killing of the 
bacteria which produce the souring of milk makes it possible to keep milk in warm 
weather a muchlonger time before souring occurs. It is therefore a great advantage 
to the dealer, and he is likely to depend upon it rather than upon adequate icing 
and cleanliness in handling his milk. There are some serious objections to com- 
mercial pasteurisation. Milk so heated should be quickly cooled, should be received 
into sterilised vessels and kept at a low temperature (below 50° F.). If these pre- 
cautions are not taken bacteria develop rapidly and the milk may after 24 hours be 
more dangerous than if it had not been heated at all; since, unlike raw milk, it does 
not usually sour and reveal its contaminated condition. Commercial pasteurisation 
should be permitted only under the most careful restrictions, and the can or bottle 
containing pasteurised milk should indicate the degree and time of heating. 



152 



NUTRITION. 



adoption. Pasteurisation, however, requires considerable care, intelli- 
gence, and special apparatus ; if not properly done it may be worse than 
nothing. Moreover, pasteurised milk can not, in very hot weather, be 
kept without ice as long as it may be necessary to keep milk. Steril- 
isation at 212° F. (100° C.) is much simpler; it may be done with many 
simple and inexpensive forms of apparatus or even without any special 
apparatus. Where no ice is available, it is certainly safer in hot weather 
than pasteurisation. Among the poor of our large cities, in summer, 
heating to 212° for an hour is to be advised as the most satisfactory, and 
indeed the only efficient, method of sterilisation. It should not be for- 
gotten that the use of such milk as the sole diet for a long time is at- 
tended with a certain amount of risk; and one should always be on the 
watch for the soreness of the legs and the spongy gums that indicate the 
beginning of scurvy, as well as for the more general symptoms of mal- 
nutrition. Heating to 212° F. on two successive days is also to be recom- 
mended where milk must be kept for one or two weeks, as upon ocean 
journeys. 

Methods of Heating Milk. — Milk should be sterilised preferably in 
small bottles, each one of which contains a sufficient quantity for one 
feeding. These bottles may be plugged with cotton or corks, or special 
stoppers may be used. Soxhlet's apparatus may be employed, or Ar- 
nold's, or any one of a half dozen others sold in the shops. All that is 
really necessary is to expose the bottles on all sides to live steam in a 
closed vessel. It can be done effectively in any tin vessel which has a 
closely fitting cover and a perforated bottom, and which can be placed 





Fig. 25. — Freeman's Pasteuriser. 
A, Bottles in position for heating; B, method of cooling. 



over a pot of boiling water. Sterilisation at 212° F. is usually continued 
for one hour. The bottles should then be cooled in water as quickly as 
possible and placed upon ice or in the coolest place available. 

A simple apparatus for pasteurising milk has been devised by Free- 
man (Fig. 25). In this the temperature is raised to 155° F. (68° C.) 



COW'S MILK. 153 

by hot water. 1 Another useful form of apparatus is that of the Walker- 
Gordon Laboratory Company, which contains a thermometer so that any 
desired temperature can be secured. An essential step in pasteurising 
milk is rapid cooling. After forty-five minutes the bottles should be 
removed from the pasteuriser and placed in tepid water and afterward 
in ice-water, where they should remain half an hour before being placed 
in the cold room or ice chest. 

Limitations of Milk Sterilisation. — While pasteurising or sterilising 
milk kills nearly all the living organisms, it destroys few of the spores, 
and probably but a small. proportion, if any, of the toxins. Before sterili- 
sation milk may contain the products of bacterial growth in such quan- 
tity and of such a character as to render it unfit for food. Again, the 
fewer the spores and spore-bearing bacteria which the milk contains, the 
more effective the sterilisation. The cleaner the milk the better will 
be the result. 

Sterilised milk requires the same modification for infant feeding as 
raw milk. There is no evidence to show that its digestibility is en- 
hanced by the process of heating. 

The sterilisation of milk is useful, first, for the destruction of 
pathogenic germs, particularly typhoid and tubercle bacilli; secondly, 
for the destruction of the bacteria causing fermentation, thus enabling 
one to feed with safety milk in which, though it may be forty-eight hours 
old, no important fermentative changes have occurred. As a therapeutic 
measure sterilised milk is useful in various forms of gastric or intestinal 
infection such as typhoid fever, dysentery, diarrhoea, etc. In certain 
of these conditions no milk is admissible; at other times sterilised milk 
may be given when raw milk would be harmful. 

Shall all Milk used for Infant Feeding be Sterilised ? — In summer only 
the cleanest milk which has been handled in the best manner can safely 
be used without heating. In winter, the heating of milk is not neces- 
sary, provided the source of supply is known to be good. So long as 

1 Freeman's apparatus is used as follows: The pail is filled to the groove with 
water, which is then raised to the boiling point. The bottles of milk are dropped into 
their places in the cylindrical cups, sufficient water being poured into each cup to 
surround the bottle, this water acting as the conductor of heat. The pail is now 
removed from the stove and placed upon a board or other non-conductor, and the 
receptacle containing the bottles of milk is set inside and the cover replaced. The 
volumes of milk and water have been so calculated that in ten minutes they are both 
at a temperature of 155° F. The water contains heat enough to maintain this, with 
very slight variations, for twenty minutes. In half an hour the bottles of milk are 
removed and cooled rapidly by being placed in a water-bath, the water being changed 
once or twice; or, better, by setting the pail in a sink and allowing the cold water to 
run from a faucet through a piece of rubber pipe into the pail, overflowing into the 
sink. This rapid cooling is very important. The bottles are then put in the refrigera- 
tor. This apparatus may be obtained from James Dougherty, 411 West Fifty-ninth 
Street, New York. 



154 NUTRITION. 

milk is produced and handled as the bulk of it is at present, not being 
delivered in large cities until it is considerably over twenty-four hours 
old, and not consumed until over forty-eight hours old, some form of 
heating should invariably be practised in hot weather ; also, where there 
is any doubt about the dairy hygiene or the health of the cows; and 
finally, during epidemics of typhoid fever, diphtheria, and scarlet fever. 

It is quite possible to produce milk which does not need sterilisation; 
the conditions to be fulfilled have been already detailed. There are 
speeial dairies supplying such certified milk to many of our large cities, 
and their number may be very greatly increased if the medical profession 
will use its influence in this direction. My preference for infant feeding 
is a milk so clean and fresh that it may be safely given without heating, 
feeling as I do that all forms of sterilisation do impair, though possibly 
only to a slight degree, its nutritive properties. It should, however, be 
borne in mind that there are some delicate infants with feeble digestion 
who thrive better upon sterilised milk than upon raw milk in which the 
bacterial content is quite low; for, even though not numerous, bacteria 
may yet do harm to such children. Healthy infants with good digestion 
may do well upon raw milk even though the number of bacteria is quite 
large, i. e., 100,000-1,000,000 per c.c. ; while delicate infants or those 
with digestive disturbances may be seriously affected by such milk. In 
the country where milk is obtained fresh and used before it is twenty-four 
hours old, sterilising is usually unnecessary if the cows are healthy and 
the milk properly handled. 

Peptonised Milk. — Milk is peptonised through the agency of a sub- 
stance derived from the pancreas, usually that of the pig. This is known 
in the market as " extractum pancreatis," the active ferment being the 
trypsin. As this acts only in an alkaline medium, bicarbonate of soda 
should first be added to the milk. The purpose of peptonising is to 
secure a partial digestion of the protein of milk before feeding. 

Milk which has been peptonised ten minutes is not altered in taste; 
if, however, the process is continued for twenty minutes, a slightly bitter 
taste is noticed. This increases with the duration of the process. Pep- 
tonising may be arrested at any stage by raising the milk to the boiling 
point; but if the milk is to be fed at once this is not necessary. 

Peptonised milk is to be modified according to the child's age and 
digestion. It is useful only where there is feeble protein digestion, and 
during attacks of acute gastric indigestion in infancy. It is not advis- 
able to continue its use indefinitely, for in this case the stomach grad- 
ually becomes less and less able to do its work. Its prolonged use is 
sometimes followed by scurvy. 

Condensed Milk. — This is prepared by heating fresh cow's milk to 
212° F. for twenty minutes for sterilisation, and then evaporating in 
vacuo, so that one part of condensed milk represents about two and a 



CROW'S MILK. 



155 



half parts of the original milk. It is preserved in tin cans, with the 
addition of cane sugar in the proportion of nearly seven ounces to a 
pint. The changes, therefore, to which the milk has been subjected are : 
evaporation of a part of the water, sterilisation, and the addition of 
cane sugar. Fresh or unsweetened condensed milk is to be obtained in 
many large cities. 

The composition of condensed milk is shown in the following table; 
also the results obtained when it is diluted with six, twelve, and eighteen 
parts of water. 





Condensed 
Lmilk. 1 


With 6 parts 
of water 
added. 


With 12 parts 
water. 


With 18 parts 
of water. 


Fat 


Per cent. 

9.61 
8.01 

54.94 

1.78 
25.66 


Per cent. 

1.37 
1.14 

7.89 

0.25 
89.35 


Per cent. 

0.73 
0.61 

4.75 

0.13 

94.28 


Per eent. 

0.50 


Protein 


0.42 


«„.».» i Cane, 42.91 1 
Su S ar \ Milk, 12.03 \ • • ■ 
Salts 


2.90 
0.09 


Water 


96.09 







1 Analysis of Borden's Eagle-Brand condensed milk. 



The reasons both for the success and for the failure of condensed 
milk as an infant-food are apparent from a study of its composition. As 
a temporary food it is often useful, first because it has been sterilised, 
but chiefly because both the fat and the protein of cow's milk have been 
reduced by the usual dilution to a point at which an infant with a very 
weak digestion can manage them, while it furnishes an abundance of 
sugar. Infants fed upon condensed milk are often fat, but have, as a 
rule, feeble resistance, and when attacked by acute disease, especially of 
the intestinal tract, they succumb more readily than do those reared in 
almost any other way. It is rare to see a child reared on condensed 
milk who does not show to some degree evidence of rickets. The pro- 
longed use of condensed milk is a frequent cause of scurvy. Condensed 
milk fails as a permanent food because it consists too largely of carbo- 
hydrates, and is lacking in fat. It is admissible for temporary use dur- 
ing attacks of indigestion, for infants with feeble digestion, especially 
in summer, for very young infants during the first two or three months, 
or among the very poor, when the cow's milk which is available is still 
more objectionable. It should not be used as a permanent food where 
good, fresh cow's milk can be obtained. In travelling it is often the 
most convenient as well as the safest food to use. It should be diluted 
twelve times for an infant under one month, and from six to ten times 
for those who are older. 

To fresh condensed milk no addition of cane sugar has been made. 
It requires essentially the same modification as ordinary cow's milk. For 



156 NUTRITION. 

routine use it should be diluted with from eight to twelve parts of 
water, and sugar added. 

Dried Milk. — Dried milk sold under various names has recently been 
put upon the market. It is prepared either from whole milk or from 
skimmed milk. The process of manufacture most extensively employed 
is that of spraying the milk upon hot revolving cylinders by which means 
the water is driven off almost instantaneously. Dried milk is a sterile 
white powder and in sealed cans keeps indefinitely. When eight parts 
by volume of water are added (one level teaspoonful to the ounce) it 
approximates in composition the original milk. It may be further 
modified if desired. Its application is similar to that of condensed milk 
over which it presents obvious advantages in travelling ; it is open to the 
same objections as a permanent food, and should not be advised when 
fresh milk can be obtained. 

Buttermilk and Other Forms of Fermented Milk. — Various forms of 
fermented milk are in use which differ according to the milk used and 
the process followed. They resemble each other in that the fermentation 
is excited by some of the varieties of lactic acid organisms, in some cases 
with the addition of yeast, which ferment a portion of the milk sugar. 
The ordinary buttermilk of commerce is sometimes made from sweet, 
but usually from sour cream. If from the latter, it resembles the fer- 
mented milks in that it contains little or no fat but a certain amount 
of lactic acid, the result of fermentation. It differs from them in that 
the fermentation in buttermilk is due to a great variety of lactic acid 
organisms; besides, it contains many other forms of bacteria than those 
concerned in the process of fermentation. Buttermilk should be made 
with care or it may be grossly contaminated. It, therefore, varies 
greatly in taste and considerably in composition at different times and 
under different conditions. 

Buttermilk (Vieth). 

Fat 0.50 

Milk sugar 4.06 

Lactic acid . 80 

Protein 3 . 60 

Inorganic salts . 75 

Water 90.29 

100.00 

When used as an infant food it is usually sterilised by boiling so 
that the living organisms are not given. Its low sugar content is over- 
come by the addition of milk sugar or cane sugar, sometimes also by 
barley flour or other farinaceous food, in any proportion desired. A 
formula much used in Europe is : buttermilk, one quart ; barley flour, 
two even tablespoonfuls ; water, four ounces. Cook slowly, constantly 
stirring, for twenty minutes; then add two teaspoonfuls of cane sugar. 
The advantages of buttermilk as an infant food are chiefly due to its 



COW'S MILK. 157 

low fat content and the small amount of lactic acid which it contains. 
Its cheapness is an important consideration and makes it available for 
the very poor. 

Other fermented milks, sometimes called buttermilk, are known also 
as lactic acid milk, lactobacilline, lactobacillary milk, lactone buttermilk, 
etc. They are sometimes made from whole milk but chiefly from skimmed 
milk. This is usually first sterilised' and then the ferment added in the 
form of tablet, mixture or culture from some previously fermented milk. 
The ferment consists of different varieties of lactic acid organisms; the 
one most frequently employed is known as the Bulgaricus. The prod- 
uct differs according to the exact varieties or combinations used, also 
according to the temperature maintained and the duration of the fer- 
mentation. A temperature of 80° to 85° F. is usually employed and this 
is continued from twelve to twenty-four hours according to the degree 
of acidity desired. The milk is then bottled and put on ice, where a 
slight change continues, although the milk alters but little for several 
days. The taste is rather pleasant unless the acidity is too pronounced. 
The product always contains a considerable amount of lactic acid: it 
should not contain alcohol or acetic acid. These fermented milks are 
sometimes used in acute disease, but chiefly in chronic intestinal con- 
ditions. They are not adapted to continuous use in infant feeding. 

Kumyss has been made by the Tartars for centuries from mare's 
milk. It is made in this country from cow's milk, sometimes skimmed, 
but usually from the whole milk. The fermentation is generally started 
with yeast and is continued in corked bottles usually for several days, 
with frequent agitation. Kumyss contains carbon dioxide, lactic acid, 
alcohol and traces of butyric and acetic acid. The acidity and the taste 
depend upon the duration of the process. 

Zoolak or matzoon is made from whole milk which is first sterilised 
and then has added to it a ferment which contains some form of yeast. 
It differs from kumyss chiefly in that the process is carried on in open 
vessels and the carbon dioxide allowed to escape. It is a thick smooth 
liquid and has a taste resembling that of sour cream. 

Both kumyss and zoolak are better adapted for use with older chil- 
dren than with infants; they are chiefly valuable in cases of chronic 
intestinal indigestion. For infants they should be diluted with water 
and often given with a spoon since they are too thick to go through the 
ordinary nipple. 

Protein Milk (Eiweiss Milch of Finkelstein). — The object of this 
preparation is to secure a milk for infant feeding which is low in sugar, 
high in protein with a moderate amount of fat. It is made as follows: 
To one quart of whole milk is added half an ounce of rennet or enough 
to coagulate the casein. The whey is strained off through muslin, by 
suspending the curd for an hour. The curd is then rubbed through a 



158 



NUTRITION 



fine wire sieve. One pint of fermented milk (buttermilk or any of those 
mentioned above may be used) is now added, also one pint of water. 
The finely divided curd is so held in suspension in the mixture that it 
will pass through a nipple with a moderately large opening. It is 
easier to rub the curd through the sieve if the fermented milk is 
gradually added during the process. The average composition of pro- 
tein milk is: fat, 2.5 per cent; sugar, 1.5 per cent; protein, 3 per 
cent; salts, 0.5 per cent. The other ingredients are pretty uniform; but 
the fat percentage varies considerably, according to the amount present 
in the original milk and in the fermented milk. Under certain condi- 
tions it is desirable to vary the fat percentage. For acute conditions 
protein milk is used without additional carbohydrates; for prolonged 
use as an infant food, sugar, preferably maltose, should be added. 

Junket or Curds and Whey. — Junket is made as follows: To one 
pint of fresh lukewarm cow's milk are added two teaspoonfuls of essence 
of pepsin, liquid rennet, or a junket tablet. It is stirred for a moment 
and then allowed to stand at the room temperature until firmly coag- 
ulated. Junket is useful in the feeding of older children, but should 
not be given to infants. 

Whey. — The milk is coagulated with rennet as above, the curd is 
then broken up, and the whey strained through muslin by suspension. 
The composition of whey varies somewhat, depending upon the way 
in which it is prepared. If it is desired to have as little fat as possible, 
skimmed or fat-free milk should be used, and the whey should be 
strained through fine muslin without pressure. If it is desired to retain 
some of the fat, whole milk may be used, cheesecloth, and more pressure. 
The protein of whey is chiefly lactalbumin. 

Whey is useful particularly in the feeding of very young infants. It 
has been made the basis of milk modifications, the purpose of which 
is to give a larger proportion of lactalbumin and a smaller proportion 
of casein than exist in any dilution of cow's milk. 

Whey. 





Average 
46 analyses 
(Koenig). 


From 
whole milk 
( Adriance) . 


From 
fat-free milk 
(Adriance). 


Protein 


0.86 

0.32 

4.79 

0.65 

93.38 


0.94 
0.96 
5.49 
0.48 
92.13 


1.17 


Fat 


04 


Sugar 


5.36 


Salts 


52 


Water 


92 91 






Total 


100.00 


100.00 


100.00 



Wine whey is made by simply adding sherry wine to whey prepared 
in the usual manner, in the proportion of one part to four of whey, or 



BEEF PREPARATIONS. 



159 



possibly better by using the wine to coagulate the milk (Still). The 
wine (cooking sherry preferred) is added to the milk in the proportion 
mentioned and the mixture slowly brought to the boiling point. After 
standing off the fire for three or four minutes it is strained through two 
layers of coarse muslin, or cheesecloth. Sherry whey is useful as an 
emergency food for short periods in acute illness for children who will 
take very little food; it is seldom given alone, but alternating with 
some other food. 

BEEF PREPARATIONS. 

The nutrient value of these preparations is to be measured by the 
amount of albumin they contain — their stimulant properties by the pro- 
portion of extractives. 

Beef Juice. — Expressed beef juice is made as follows: A piece of 
round steak is slightly broiled, and the juice pressed out by a meat-press 
or a lemon-squeezer. Two or three ounces can ordinarily be obtained 
from one pound of steak. This is seasoned with salt and given cold or 
warm, but not heated sufficiently to coagulate the albumin in solution. 

An excellent method of making beef juice without cooking is 
by taking one pound of finely chopped lean beef and eight ounces of 
water and allowing this to stand in a covered jar upon ice from 
six to twelve hours. The meat is then squeezed by twisting in coarse 
muslin. It is seasoned with salt and given as above. This is not quite 
so palatable as that obtained by the first method, because it contains a 
much smaller proportion of extractives, but it is much more economical. 
If the raw juice is added to milk in the proportion of two or three tea- 
spoonfuls to each feeding, the taste will not be noticed. The milk should 
not be warmed above 100° F. before the addition of the juice. 

The composition of the two products is given below. 

Patients should be encouraged to use beef juice freshly prepared 
from meat when the latter can be obtained, rather than the beef prepara- 
tions of the shops. 

Beef Juice. 1 





I. 

Expressed juice 
from 1 lb., warm 
process; quan- 
tity, 2H oz. 


II. 

Cold process, 
1 lb. beef, 8 oz. 
water; quan- 
tity, sy 2 oz. 


Protein 


2.90 
0.60 
3.40 
0.20 
92.90 


3.00 


Fat • 




Extractives . 


1.90 


Salts 


0.20 


Water 


94.90 








100.00 


100.00 



Analysis made for the author by E. E. Smith, Ph.D., M.D. 



160 NUTRITION. 

Beef extracts are not to be considered in any sense as foods. Kem- 
merich has shown that animals receiving nothing else died of starvation, 
and sooner even than when everything was withheld. According to 
Chittenden, they contain no nitrogen in the form of protein, but only in 
combination with the soluble extractives. They are stimulants, but as 
such are often useful. 

Rare scraped beef is easily digested by most young children. There 
are many conditions in which other forms of protein are not well borne, 
where children even as young as twelve months appear to digest this 
beef -pulp without difficulty. It should be made from very rare or raw 
steak, finely scraped and well salted. A tablespoonful may be given at 
one feeding to a child of eighteen months. In nutrient properties this 
far exceeds the beef preparations in the market. The alleged danger of 
tapeworm from the use of rare scraped beef or beef juice is in this coun- 
try so slight that it may be disregarded. 

Broths. — Animal broths may be made from mutton, veal, chicken, or 
beef. A good formula for general use is the following: One pound of 
lean meat, one pint of water; stand for two hours, then cook over a slow 
fire for two hours down to half a pint. After it has cooled, skim off the 
fat and strain through a cloth. The composition of a broth so made is 
given by Cheadle as follows : 

Beef Broth. 

Protein 1 .02 

Extractives 1 . 82 

Fat 0.00 

Salts 0.88 

Water 96.28 

100.00 

From their composition it will be seen that broths are not very nutri- 
tious ; they are, however, quite stimulating, and are at times useful, par- 
ticularly where milk must be temporarily withheld. They are, however, 
not adapted to prolonged use alone. Broths which have been thickened 
with either barley or rice flour are useful for infants and older children. 

Albumin Water. — This is prepared as follows: The white of one 
fresh egg is mixed with a pint of cold water, a little salt, and a tea- 
spoonful of brandy added. It should be given cold. Albumin water 
is useful in a variety of conditions attended by gastric irritability. The 
nutritive value of this preparation, it should be borne in mind, is very 
small. 

CEREALS. 

Barley Water. — This may be made either from the grains or from 
the barley flour. When the grains are used, the following is the formula 
which I have been accustomed to employ : To two tablespoonf uls of pearl 



INFANT FOODS. 161 

barley, add one quart of water and a pinch of salt, and boil continuously 
for six hours, keeping the quantity up to a quart by the addition of 
water; strain through coarse muslin. It is an advantage to soak the 
barley for a few hours before 'cooking. The water in which it is soaked 
is not used. When cold this preparation makes a rather thin jelly. 
Its composition by analysis is as follows : 

Barley Water. 

Starch 1 . 63 

Fat 0.05 

Protein 0.09 

Inorganic Salts 0. 03 

Water 98.20 

100.00 

Almost an identical product may be obtained in an easier way by 
using prepared barley flour, one even tablespoonful to each twelve ounces 
of water, and cooking for twenty minutes. A thicker jelly when desired 
can be made by using twice as much of the barley. 

Rice, Wheat, or Oatmeal Water, etc. — These may be made in the 
same manner as the barley water, using the same proportions either of 
the flour or the grains. These are useful as additions to milk for healthy 
infants who have reached the age of five or six months; they may also 
be given in many cases of acute or chronic indigestion where milk 
must be omitted or given in small quantities. When there is a tendency 
to constipation oatmeal is preferred ; when to looseness, barley, wheat, or 
rice water. 

INFANT FOODS. 

It is not possible, nor even desirable, for a physician to know all about 
the infant foods with which the market is flooded. He should, however, 
know at least that they are not perfect substitutes for breast-milk, that 
as permanent foods they are greatly inferior to properly modified cow's 
milk, and that they are capable of doing and have done much positive 
harm. Eickets and scurvy have so frequently followed their prolonged 
use, when given without the addition of fresh milk, and sometimes even 
when they have been given with it, that there can be no escaping the 
conclusion that they were the active cause. Their general use is con- 
demned with practical unanimity by authorities on infant feeding. Yet 
by industrious and skilful advertising they are forced upon public at- 
tention, and are extensively used by the laity and even by the medical 
profession. They are expensive. They add little or nothing to our re- 
sources in infant dietetics; in fact, they tend to retard rather than ad- 
vance our knowledge of this subject. 

There are, however, a few occasions when some of these preparations 
12 



162 



NUTRITION. 



may be useful as temporary expedients or when nothing better can be 
obtained. They should be used only with a very definite knowledge of 
exactly what they do and what they do not contain. Their name is 
legion; but those most commonly employed in this country may be 
grouped as follows : 

1. The Milk Foods. — Nestle's food is perhaps the most widely known. 
The others closely resembling it in composition are the Anglo-Swiss, the 
Franco-Swiss, the American-Swiss, and Gerber's food. These foods are 
essentially sweetened condensed milk evaporated to dryness, with the 
addition of some form of flour which has been dextrinised; they all 
contain a considerable proportion of unchanged starch. 

2. The Liebig or Malted Foods. — Mellin's food may be taken as a 
type of the class. Others which resemble it more or less closely are 
Liebig's, Horlick's malted milk, and cereal milk. Mellin's food is com- 
posed principally (80 per cent) of soluble carbohydrates. They are de- 
rived from malted wheat and barley flour, and are composed chiefly of 
a mixture of dextrin, dextrose, and maltose. 

3. The Farinaceous Foods. — These are imperial granum, Bidge's 
food, Hubbell's prepared wheat, and Robinson's patent barley. The first 
consists of wheat flour previously prepared by baking, by which a small 
proportion of the starch— from one to six per cent — has been converted 
into sugar. In chemical composition these four foods are very similar, 
consisting mainly of unchanged starch which forms from seventy-five to 
eighty per cent of their solid constituents. 

4. Miscellaneous Foods. — Under this head may be mentioned Carn- 
rick's soluble food and Eskay's food. The composition of these is given 
in the following table : 

The Composition of Infant-Foods. 1 



Fat 

Protein 

Cane sugar 

Dextrose 

Lactose (milk sugar) 

Maltose 

Dextrins 

Total Soluble carbo- 
hydrates 

Insoluble carbohy- 
drates (Starch) . . 

Inorganic salts .... 

Moisture 



Nestle's 
food. 



Per cent. 

5.50 
14.34 
25.00 



6.57 
27.36 

58.93 

15.39 
2.03 
3.81 



Mellin' 
food. 



Per cent. 

0.24 
11.50 



60. SO 
19.20 

80.00 



3.59 
4.73 



Eskay's 
food. 



Per cent. 

1.16 

5.82 



53. 46 2 

14.35 

67.81 

21.21 
1.30 
2.70 



Malted 
milk. 



8.78 
16.35 



49.15 
18.80 

67.95 



3.86 
3.06 



Ridge's 
food. 



Per cent. 
1.11 

11.81 

O'o2 



1.28 
1.80 

76.21 

0.49 

8.58 



Imperial garn- 
granum. food< 



Per cent. 

1.04 
14.00 

0'l2 



1.38 

1.80 

73.54 
0.39 
9.23 



Per cent. 

7.45 
10.25 



27.08 

37.37 
4.42 
3.42 



1 With the exception of Nestle's food and Carnrick's soluble food, these analyses 
were made for the author by E. E. Smith, Ph.D., M.D., of samples purchased in the 
open market. 2 Chiefly lactose. 3 Largely maltose. 



PLATE III. 



WOMAN'S MILK. 




CANNED CONDENSED MILK. 



Proteios. 

Fat 

Soluble Carbohydrates (sugar). 

Salts 

INSOLUBLE CARBOHYORATES Utawch* 



fi 



t 



MELLIN'S FOOD. 






p 



MALTED MILK. 




NESTLE'S FOOD. 



CARNRICK'S SOLUBLE FOOD 








IMPERIAL GRANUM. 



_ : 



" ] 



Chart showing the solid ingredients of various infant foods 
as compared with those of woman's milk. 



CHOICE OF METHODS OF FEEDING. 163 

A better idea of the composition of these foods can be obtained by a 
study of the accompanying chart (Plate III), which shows their solid con- 
stituents as compared with those of woman's milk. The essential features 
of the foods are seen at a glance — i. e., they are all composed principally of 
carbohydrates and are lacking in fat. Some of them contain a large pro- 
portion of unchanged starch. Furthermore, their protein, though often 
sufficient in amount, is chiefly vegetable, not animal protein. No one of 
them can be regarded in any sense as a proper substitute for breast-milk. 

Some of these foods — Nestle's and other milk foods, malted milk, 
cereal milk, and Carnrick's food, and even some of the farinaceous foods, 
like imperial granum — are advertised as substitutes for breast-milk 
and recommended for use alone. Others, such as Mellin's, Liebig's, and 
Eskay's foods, are intended to be used with milk. The use of any of 
the commercial foods alone is admissible only for short periods during 
derangements of digestion, when we wish to withhold for the time all 
fat and milk protein. Their prolonged use almost invariably produces 
some grave disorder of nutrition, most frequently rickets or scurvy. 
Those foods which require in their preparation the addition of milk 
are open to less serious objections, but are not necessary or even desir- 
able. They should never be used with condensed milk. When added to 
fresh milk they may furnish the additional carbohydrates required by an 
infant fed upon a diluted cow's milk. In such a case they take the 
place of milk sugar or cane sugar in the milk modification. There is 
no proof to sustain the claim that they increase the digestibility of cow's 
milk. Farinaceous foods may be used as an addition to milk after the 
sixth or seventh month and during the second year. 



CHAPTER III. 
INFANT FEEDING. 

CHOICE OF METHODS OF FEEDING. 

The different methods of feeding which are available are: 

1. Breast-feeding, either by the mother or by a wet-nurse. 

2. Mixed feeding, or a combination of nursing and artificial feeding. 

3. Artificial feeding exclusively. 

In deciding by which one of these methods a child shall be fed, many 
circumstances must be taken into consideration : the vigour of the child, 
the health of the mother, and especially the surroundings, since these 
determine very largely the success or failure of any method employed. 

Maternal Nursing. — This is the natural and the ideal method of 
infant feeding. Every mother should nurse her infant unless there are 
some very weighty reasons to the contrary. The physician should do all 



164 NUTRITION. 

in his power to encourage maternal nursing and to promote its success. 
He should explain to the mother how important breast-milk is for the 
child; that fully four-fifths of the deaths under one year are in infants 
who are artificially fed. He should also make clear the conditions by 
which alone successful nursing can be accomplished; viz., proper 
diet, regular habits of sleep and exercise, and a simple life, in so far as 
possible free from causes of nervous excitement, fatigue, over-work, or 
worry. Social engagements should be avoided. Nursing may be fur- 
thered by proper care of the nipples before delivery, and by attention 
to them during the early days of nursing to prevent fissures and mastitis, 
which so often interrupt successful nursing. 

In spite of all efforts to the contrary, it is nevertheless a fact that 
the capacity for maternal nursing is steadily diminishing in this coun- 
try, chiefly in the cities, but to a considerable degree in the rural districts 
as well. Among the well-to-do classes in New York and its suburbs, 
of those who have earnestly and intelligently attempted to nurse, less 
than 25 per cent, in my experience, have been able to continue satis- 
factorily for as long as six months. An average city mother who is able 
to nurse her child successfully for the entire first year is almost a phe- 
nomenon. Among the poorer classes in our cities a decline in nursing 
ability is also seen, although not yet to the same degree as in the higher 
social scale. These are facts that must be taken into account in decid- 
ing the question of feeding. While nothing is so good as good maternal 
nursing, no method of feeding gives much worse results than poor nurs- 
ing. Among the classes of society where most of the maternal nursing 
is very poor, but where every facility can be afforded for the best 
artificial feeding, one should not be slow to adopt the latter in cases of 
doubt. Among the poor and ignorant, however, where artificial feeding 
can not be carried on with anything like the same chances of success, all 
possible efforts should be made to increase maternal nursing as the most 
effective means of reducing infant mortality. 

When Maternal Nursing should not be Attempted. — (1) No mother 
who is the subject of tuberculosis in any form, whether latent or active, 
should nurse her infant; it can only hasten the progress of the disease 
in herself, while at the same time it exposes the infant to the danger of 
infection. (2) Nursing should seldom be allowed where serious com- 
plications have been connected with parturition, such as severe haemor- 
rhage, puerperal convulsions, nephritis, or puerperal septicaemia. (3) If 
the mother is epileptic. (4) If the mother is suffering from any serious 
chronic disease or is very delicate, since great harm may be done to her 
without any corresponding benefit to the child. (5) Where experience 
on two previous occasions under favourable conditions has shown her 
inability to nurse her child. (6) When no milk is secreted. With ref- 
erence to the fourth and fifth conditions, an absolute opinion can not 



CHOICE OF METHODS OF FEEDING. 



165 



always be given at the outset. As a rule, mothers are more likely to 
succeed in nursing first or second children than subsequent ones. My 
own statistics indicate that in general the capacity for lactation dimin- 



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Fig. 26. — Weight Curve of Nursing and Artificial Feeding Compared. Both in- 
fants were strong, well nourished, and in good surroundings. The bottle-fed infant 
was never once put to the breast; fed from the milk laboratory. First formula: Fat 
1 per cent, sugar 5 per cent, protein 0.5 per cent. At six weeks taking: Fat 3 per 
cent, sugar 7 per cent, protein 1.25 per cent. It will be observed that the nursing 
infant made more rapid progress during the first few weeks, while the bottle-fed in- 
fant n.ore than made up for this between the fifth and ninth month, for weaning be- 
came necessary in the other child owing to the gradual failure of the mother's milk. 
The stationary weight was the result of this condition, and the irregular subsequent 
gain was incident to the change of food. 



ishes with each successive pregnancy. My inclination as a result of 
increasing experience is not to allow nursing in either of these con- 
ditions, provided the means for proper artificial feeding can be com- 
manded. The chances of success are so small and the difficulties are so 
increased by even a few weeks of bad nursing that I prefer not to put 
the child to the breast at all, even for the first two or three days. The 
breasts are bound up at once and kept bandaged. When one begins with 
healthy digestive organs the difficulties with artificial feeding are rela- 
tively few, and it is usually successful. 

Artificial Feeding vs. Wet-Nursing. — When maternal nursing is im- 
possible or undesirable, the milk of another woman would seem to be 



166 NUTRITION. 

the most natural and best substitute. While this is theoretically true, 
the practical obstacles are so many as to put wet-nursing out of the 
question as a general method of feeding. We have in America no peasant 
class like that of Europe to draw upon ; and in the class which furnishes 
most of our wet-nurses the capacity to nurse has steadily diminished. 
The expense of a wet-nurse — twenty-five to thirty-five dollars a month 
in Xew York — the danger of transmitting contagious disease, and the 
difficulty of obtaining proper care for her own infant, are all very seri- 
ous objections to wet-nursing. The recent advances in artificial feeding 
have placed it now on quite a different footing from that which it for- 
merly occupied. While it is true that good breast-milk is unquestionably 
the best food, it is equally true that properly modified cow's milk is a far 
better food than the milk of many wet-nurses who are employed. These 
facts added to the constantly increasing difficulty of obtaining good 
ones have caused wet-nurses to be pretty generally discarded, even in 
our large cities, where formerly no other substitute for maternal nursing 
was considered. 

There are, however, some conditions in which they are necessary, 
even indispensable. Some infants, usually those who have been badly 
started, can not be made to thrive upon any form of artificial feeding. 
There are also premature infants and other very delicate ones whose 
powers of assimilation are so feeble that they are reared under any cir- 
cumstances only with the greatest difficulty, but whose chances of life 
are much increased by a good wet-nurse. Again, in young infants who 
have been suffering for some time from chronic indigestion and failing 
nutrition, the symptoms of acute inanition sometimes develop with great 
rapidity and severity. From such a condition, apparently hopeless, in- 
fants may sometimes be rescued by the timely assistance of a good 
wet-nurse. 

The difficulties in the way of successful infant feeding in foundling 
asylums and other institutions for young infants are such that in them 
partial wet-nursing at least should be employed whenever possible. 

Mixed Feeding. — Mixed feeding, or a combination of nursing and 
artificial feeding, may be employed whenever the supply of the nurse is 
insufficient. The use of one or two feedings a day from the bottle after 
the third or fourth month may do much to relieve the mother from the 
strain of nursing entirely without disturbing the infant's progress. 
During the later months more feedings may be introduced for the pur- 
pose of gradual weaning. 

BREAST-FEEDING. 

Care of the Breasts during lactation. — For the safety of both mother 
and child it is essential that the most scrupulous attention be given to 
cleanliness. The nipples, and the breasts as well, should always be care- 



BREAST-FEEDING. 1 67 

fully washed after each nursing. Usually plain water is sufficient, or a 
weak boric-acid solution may be employed. 

Nursing during the First Days of Life. — This is necessary, to accus- 
tom the child and the mother to the procedure, and to empty the breasts 
of the colostrum; it probably also promotes uterine contractions. All 
these results can be attained by putting the child to the breast on the 
first day once in six hours, on the second day once in four hours. The 
child gets from the breast only from four to six ounces a day during 
the first two days. Did it require more nourishment before the milk- 
flow is fully established, we may be sure that Nature would not have 
been so late with her supply. The common practice of administering 
to an infant a few hours old all sorts of decoctions, with the idea that 
because it cries it is suffering from colic, can not be too strongly con- 
demned. A certain amount of crying is necessary. In exceptional cir- 
cumstances, when an infant is unusually large and strong and cries 
excessively, it may be necessary to give food even on the first day; but 
this is not to be the rule. A little warm water should first be given; 
from two to four teaspoonfuls at a time are sufficient. If this does not 
satisfy the child, regular feeding should be begun on the second day. 
Should the milk be delayed beyond the second day, the child should 
be put to the breast at regular intervals, but only for two or three min- 
utes, and then given the bottle thereafter if still hungry. It is impor- 
tant not to cease in our efforts to induce a secretion for several days 
longer, and the best of all means is the stimulation of the child's sucking. 

Nursing Habits. — Good habits of nursing and sleep are almost as 
easily formed as bad ones, provided one begins at the outset. A vast deal 
of the wear and tear incident to the nursing period may be avoided if 
the child is trained to regular habits. Attention to these minor points 
often makes all the difference between successful and unsuccessful nurs- 
ing. After the third day, ten nursings in the twenty-four hours are quite 
sufficient for the first weeks, and no more should be allowed. An infant 
at this age can usually be depended upon to take at least one long sleep 
of from four to five hours in the twenty-four. For the rest of the day 
the child should be awakened, if necessary, at the regular nursing time, 
and put to the breast; this plan being continued until nine o'clock at 
night. He should then be allowed to sleep as long as he will, and but 
two nursings given between this hour and seven in the morning. In the 
course of two or three weeks a healthy infant can usually be trained to 
nurse and sleep with almost perfect regularity, frequently, when a month 
old, going six hours regularly at night without feeding. A trained nurse 
of my acquaintance states that out of thirty-three infants of which she 
had the care from birth, thirty-one were trained without difficulty in the 
manner stated. Of course, success in training must rest almost entirely 
with the nurse; but the physician should at least appreciate the impor- 



168 



NUTRITION. 



tanee of proper training and lend it his support. So far as the child 
is concerned, regular habits of feeding and sleep, and regular evacua- 
tions from the bowels, which nearly always go with them, are most 
important factors in infant hygiene. 

Schedule for Breast-Feeding. 

Night nursings 
' - between 9 p.m. 
and 7 a.m. 



First day 

Second day 

Third to twentieth day 
Third to ninth week . . 
Third to fifth month . . 
After the fifth month . . 




Relieving the mother of night-nursing after the child is five months 
old is of the greatest value, and will often enable her to continue lacta- 
tion, when otherwise it would be brought to an abrupt termination. On 
no account should the child be allowed to sleep upon the mother's breast, 
nor in the same bed with the mother. The temptation to frequent nurs- 
ing is thus largely removed. No mere sentiment in regard to these mat- 
ters should be allowed to interfere with the plain dictates of reason and 
experience. 

Symptoms of Unsuccessful Nursing during the Early Weeks. — At- 
tempts at maternal nursing so often result in failure, jeopardising the 
health, and even endangering the life of the child, that it becomes a 
matter of the greatest importance to decide this question of nursing 
aright, and as early as possible. On the one hand, one should not hastily 
wean a child on account of symptoms which may have no connection 
with the food, nor should one advise weaning when the indigestion from 
which the infant is suffering is due to causes which are temporary and 
remediable. On the other hand, nursing should not be continued simply 
because a conscientious mother desires it, when every indication points to 
failure. If artificial feeding is to be employed the difficulties are fewer 
when it is begun early than after the digestive organs have been deranged 
by several weeks of poor nursing. These cases form a very large group 
and present peculiar difficulties in practice. While a decision is being 
reached as to the ability of the mother to nurse, there is required close 
observation and a careful study of all the conditions, and even then the 
physician is liable to make mistakes in judgment the results of which 
may be serious. 

The body-weight gives valuable information. The child does not 
gain or continues to lose after the usual initial loss of the first three 
or four days. Observations on the weight at least twice a week are 



BREAST-FEEDING. 169 

necessary, and in cases presenting special difficulties the weight should 
be taken daily. ' 

At times there may be no vomiting, diarrhoea, or even severe colic, 
yet the child may fret and worry continually, sleep but little, and show 
a general discomfort. In other cases definite symptoms of gastric indi- 
gestion may be present, usually vomiting or frequent regurgitation of 
small amounts of undigested milk, later mixed with mucus; eructations 
of gas with or without vomiting may occur, and distention of the stom- 
ach with gas and gastric colic may follow. 

More often the symptoms of indigestion are intestinal. Occasionally 
there is constipation, but as a rule the stools are frequent, thin and 
green, containing flaky masses of undigested milk, and, after a short 
time, mucus which is frequently in large amount. The odour of the 
discharges may be slightly sour or there may be none at all. At times 
there is much gas and the stools are sour and irritating. If constipation 
is present there is apt to be severe colic and abdominal distention. The 
almost uniform absence of any elevation of temperature in these cases 
points strongly against the existence of an intestinal infection, which is 
further indicated by the prompt recovery under appropriate treatment. 

Before considering the case one of inadequate nursing, or simple indi- 
gestion in a nursing infant, one should be careful to exclude organic 
conditions in the child, particularly hypertrophic stenosis of the pylorus. 
The diagnosis of unsuccessful nursing should include the changes in the 
milk and if possible the causes of these changes. 

As the first step one should endeavour to gain some idea as to the 
quantity of milk secreted. During the first week, particularly from the 
second to the fourth day. the temperature may be elevated quite apart 
from septic or inflammatory conditions or even evidences of indigestion. 
This is particularly seen where the breasts secrete almost nothing (see 
Inanition Fever). Often when the milk is very scanty something may 
be learned from the manner in which the child takes the breast. Where 
the milk is abundant, five or six minutes are often sufficient. If the milk 
is very scanty, an infant will frequently nurse half or three-quarters of 
an hour and then stop, more because he is exhausted than because he is 
satisfied. Sometimes, when the breasts are practically empty, the child 
will seize the nipple and nurse vigorously for a few moments, then drop 
it in apparent disgust and refuse to make any further efforts. The only 
satisfactory way of determining the quantity of milk secreted is to weigh 
the infant before and after each nursing. If the milk is merely scanty, 
but not otherwise abnormal, the infant does not gain, but shows no symp- 
toms of indigestion, such as vomiting, colic, or undigested stools, and 
he frets and cries from hunger only. 

An excessively rich milk is usually found under the following con- 
ditions : The mother is in good health, has large breasts which are full 



170 



NUTRITION 



and tense at nursing time. In most cases she is upon a very abundant 
diet, getting little or no exercise, and frequently taking some alcoholic 
beverage with the notion that because the child is not thriving the milk 
is poor. The child may be colicky, sleepless, and uncomfortable, may 
vomit, may have frequent stools containing much undigested food, and 
may be losing in weight. A similar condition is often seen when a wet- 
nurse makes a change from the simple life and habits of her own home 
to the more luxurious life and diet of the family to which she goes. 
The milk then has usually a high specific gravity, is high in fat and high 
in protein. The following analyses from Eotch illustrate the point: 
No. I shows milk of a healthy but under-fed wet-nurse two days before 
change of food ; II, the milk of the same nurse after one month of rich 
food with very little exercise ; III, milk of the same nurse, the food and 
exercise being regulated. The effect of the exercise and the change in 
diet is seen in a very marked reduction in the protein. 





I. 


II. 


n, 




Per cent. 


Per cent. 


Per cent. 


Fat 


0.72 


5.44 


5.50 


Sugar 


6.75 


6.25 


6.60 


Protein 


2.53 


4.61 


2.90 


Salts 


0.22 


0.20 


0.14 



A scanty milk of a poor quality is most often seen when the mother 
is delicate or anaemic, or perhaps has had a difficult or complicated 
labour, and who besides is anxious and careworn. It is often with the 
greatest difficulty that one can secure the necessary half ounce required 
for examination. The milk is usually low in total solids and very low 
in fat. The specific gravity may be only 1.024 to 1.027, and the fat 
only one per cent or less. 

A disturbed or disordered milk secretion is sometimes seen when the 
milk is scanty, often when it is very abundant. Like the group of cases 
just mentioned, this is frequently met with when the mother's general 
health is below the normal, but particularly is it influenced by her 
nervous condition. It is the highly nervous, emotional, worried woman 
whose milk we are now considering. During the first week or two the 
secretion may be excessive and then rapidly diminish; or, though the 
milk continues abundant, the infant shows no improvement. It is most 
frequently found on examination that the milk is low in fat (0.50 to 
1 per cent), while it may be high in protein (1.75 to 3.50 per cent). 
The child's symptoms are usually those of intestinal indigestion — severe 
colic, flatulence, and frequent, green, undigested stools. Very similar 
symptoms are sometimes seen when the milk is high in fat. 

Management. — The cause of the symptoms being in the food and not 
in the child, the futility of all medical treatment will be at once appar- 



BREAST-FEEDING. 171 

ent. He who expects to relieve the symptoms of indigestion by the use of 
digestive ferments, by giving something before the nursing to dilute the 
milk, or to check frequent intestinal discharges by opium or astringents, 
will be disappointed. Temporary benefit often follows a dose of castor 
oil, but unless the milk can be materially changed in composition no 
permanent improvement in the child is to be looked for. The question 
usually to be decided relates to the continuance of nursing. We have a 
choice of four courses : ( 1 ) To continue nursing, endeavouring to correct 
the milk through treatment of the mother; (2) to partly nurse and 
partly feed from the bottle; (3) to stop all nursing temporarily, pump- 
ing the breasts meanwhile to keep up the secretion while we attempt to 
improve its character; (4) to wean at once and entirely. In deciding 
which of these courses is to be adopted we must take into consideration 
the condition of the child, the severity and duration of his symptoms, 
the findings of the milk examination, and the condition of the mother. 

While the analysis of the milk is of some value in determining the 
course to be pursued, and should, if possible, be made, it is of much less 
importance than the child's symptoms. We must be guided not by what 
the milk contains, but by how seriously it disagrees. The chemical ex- 
amination may show the milk to be of normal average in the proportion 
of its different ingredients and yet the child be seriously upset by it; 
on the other hand, a child may be doing admirably upon a milk which 
shows proportions which differ very greatly from the normal average. 
The question always concerns the effect of the particular milk upon the 
particular child. 

When the symptoms of indigestion are severe or have been prolonged 
it is usually a mistake to attempt to relieve the condition by simply 
substituting some other food for part of the nursings. This seldom 
leads to any material improvement in the symptoms, while it does con- 
fuse the result, since we can not now tell whether it is the breast or the 
bottle feeding which disagrees. A better plan is to stop nursing en- 
tirely for a time and try the bottle alone. If the symptoms are at once 
relieved the weaning should be permanent. 

When symptoms point to a scanty milk, but of fair quality — i. e., 
infant not gaining but without any particular symptoms of indigestion 
— one is often able to overcome the difficulties and continue the nursing 
to advantage. Until a decided increase in the milk has occurred the 
child should have supplementary feedings from the bottle in sufficient 
number to insure his being properly nourished. Only one or two a day 
may be required, or it may be desirable to nurse and give the bottle al- 
ternately. If the latter plan is followed, both breasts should be given at 
each nursing period for the stimulating effect upon the secretion. 

In the treatment of the mother the first thing is to secure for her an 
undisturbed rest at night. If possible, she should be entirely relieved of 



172 NUTRITION. 

the care of the infant at this time, and if feeding is necessary the bottle 
should be given. She should have a certain amount of fresh air every- 
day, driving if possible, or walking as soon as she is able to take more 
active exercise. Gentle massage of the breasts is often useful in stimu- 
lating secretion. It should be done with care and with every precaution 
against infection, and may be repeated two or three times a day for ten 
minutes. The diet should be abundant, with a large allowance of milk 
and meat, especially beef. If there is anaemia, iron should be given. 
Every means should be taken to improve the general nutrition, for what- 
ever benefits this improves the milk. If the conditions present are in- 
cident to the confinement or the convalescence, the prognosis is good; 
and in the course of a week or two very marked improvement may be 
evident, and lactation may be successfully continued. If, however, the 
conditions depend upon constitutional debility, the prognosis is much 
worse. Temporary improvement may take place, but it soon becomes 
evident that the nursing is a failure. 

When the symptoms are found to be associated with an over-rich 
milk the prospects for continuing nursing are much better than when 
the milk is poor. Unless the infant's digestion is very feeble or has been 
seriously upset either with vomiting or diarrhoea, one can usually so 
alter the milk by treating the mother as to make it possible to keep the 
baby at the breast. Alcohol should be prohibited; the diet, especially 
the amount of solid food, should be reduced, and the mother required to 
take daily exercise in the open air, particularly by walking. The in- 
tervals between nursings should be lengthened, usually to three hours. 
In many cases there is an advantage in diluting the milk by allowing the 
child to take water before putting it to the breast. The improvement 
following such a change in regimen is often immediate, and with in- 
creasing age and weight the child gradually becomes accustomed to and is 
able to digest the rich milk. If, however, the child's symptoms of in- 
digestion are of an aggravated type, whether gastric or intestinal, it 
will be necessary, even though the weight is increasing normally, to stop 
nursing entirely for a time. The breasts should be pumped at regular 
intervals and the child placed upon some other food until the symptoms 
are relieved, and then brought back gradually to breast-feeding. Should 
the infant's digestion be seriously upset a second time as soon as the 
breast is resumed, the child should be partially or entirely weaned. 

If the examination shows the milk to be of very poor quality (i. e., 
low in fat, low in total solids), whether scanty or abundant, the outlook 
is not good. It is seldom that the conditions affecting the mother to 
which such a milk is due can be removed. 

When we see a fretful, colicky, sleepless infant with either no gain 
in weight or a loss of a few ounces a week, and with stools which never 
approach the normal, and these conditions have lasted for three or four 



BREAST-FEEDING. 



173 



weeks, we are justified in taking the child from the breast at once (Fig. 
27). When the symptoms are less pronounced, and especially when, in 
spite of all discomfort and indigestion, the infant is gaining in weight, 



OF age 2 4 6 8 10 12 14 16 1 8 20 22 24 26 


19 
18 

17 

16 

15 

14 
CO 

Z 

OI2 
Q. 

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10 
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Fig. 27. — Weight Curve showing the Effect of Bad Nursing and Good Feeding. 
Maternal nursing for seven weeks; continued symptoms of indigestion; colic, fre- 
quent green passages, constant discomfort, etc. ; other treatment without avail. Im- 
mediate improvement when weaned and put on modified milk from the laboratory. 
Formula: Fat 1.5 per cent, sugar 6 per cent, protein 0.75 per cent. All symptoms of 
indigestionirapidly disappeared, the percentages were gradually increased, and a steady 
gain in weight followed. 



even though not rapidly, further efforts may be made before weaning 
is ordered. 

Summary. — Poor milk is usually low in fat and scanty in quantity, 
while the protein may be either high or low. Very rich milk is usually 
high both in fat and protein. Very poor milk can seldom be perma- 
nently improved unless the causes are very definite and of a temporary 
character. Over-rich milk can often be improved if the true explanation 
for it can be reached. Eesults are to be judged not so much by the 
change in the composition of the milk as by improvement in the infant's 
symptoms. Since good feeding gives so much better results than poor 
nursing, if circumstances are such that artificial feeding can be properly 
done, I am inclined to stop nursing after a fair trial — e. g., of two to 
three weeks — has been made, rather than waste time in prolonged efforts 
to improve the breast-milk. 



174 NUTRITION. 

Wet-Nursing. — In the selection of a wet-nurse, it is by no means 
so essential as has generally been supposed, that her child shall be of 
about the same age as the child she is to nurse, for, after the first month, 
the changes in the composition of breast-milk are insignificant. It is 
always desirable that the wet-nurse shall have nursed her own infant 
long enough to demonstrate the fact that she has an abundance of good 
milk ; hence, taking a wet-nurse at the end of the first or second week is 
always fraught with considerable uncertainty. It is the quality of the 
milk, not its age, which determines whether or not it will agree. For 
an infant over one month old, a good wet-nurse whose milk is anywhere 
between one and six months old will usually answer perfectly well; and 
even for premature infants such a milk may be used without hesitation, 
but it should at first be diluted. 

A good nurse must, first of all, be a healthy woman, free from 
syphilitic or tuberculous taint, and her throat, teeth, skin, glands, scalp, 
and legs should be carefully inspected. She must have good mammary 
glandular development. The breasts should be full and hard three hours 
after nursing. They may be very large and yet supply very little milk, 
being then composed almost entirely of fat. On the other hand, some 
smaller breasts may be almost all glandular tissue and secrete an abun- 
dance of milk. The difference in the size of a breast before and after 
nursing is one of the best guides as to the amount of milk it is secreting. 
The nipples should be free from erosions or fissures, and long enough 
for the needs of the child. Preferably a wet-nurse should be of a phleg- 
matic temperament, and of a good moral character. This is desirable 
for personal reasons, although there is no evidence of moral qualities 
being transmitted through the milk. It is desirable that she should 
be between twenty and thirty years of age, although much more depends 
upon the individual than upon the age. Other things being equal, a 
primipara should be chosen. An examination of the milk may be of 
some assistance in selecting a nurse ; but the best evidence to be obtained 
of the character of a woman's milk is the condition of her own child, 
which should always be seen before she is accepted. It often happens 
that a woman who has had an abundant supply of milk for her own 
infant has very little for another infant for the first few days in her 
new surroundings. This is usually the result of the nervous disturbance 
connected with parting from her own child, going to a new place, being 
carefully watched, etc. In such a case it should not be too readily de- 
cided that she is incompetent as a nurse, for, under most circumstances, 
with proper treatment the regular flow of milk will be re-established. 

Weaning. — Weaning should always be done gradually, when pos- 
sible, for the sake of both mother and child. Sudden weaning is apt to 
be followed by an attack of acute indigestion in the infant. This, how- 
ever, is not a necessary result, and usually depends upon the fact that 



BREAST-FEEDING. 



175 



the child is given cow's milk without sufficient dilution. Weaning in hot 
weather is usually to be avoided, but the harm from this is not nearly so 
great as sometimes results where lactation is unduly prolonged because 
of a prejudice against a change of food at this time. While there are 
many women of the lower classes who are able to nurse their children to 
advantage for the entire first year, the number of such among the bet- 
ter classes is certainly very small. By the latter, nursing can rarely be 
continued beyond the ninth, and often not beyond the sixth month, 
without unduly draining the vitality of the mother and at the same time 
harming the child. The late months of lactation, like the early months, 
require close watching. It is a common mistake to continue both ma- 
ternal and wet-nursing too long, owing to a dislike of making a change 
when things are going tolerably. If it has not been done before for 
reasons previously considered, breast-feeding should be supplemented 
by other food by the ninth or tenth month in any case. The child's 
weight is a good guide as to time and amount to be given. In the ab- 
sence of evident signs of disease, a stationary weight for several weeks 
makes weaning advisable ; a steady loss makes it imperative. 



MONTH OF AGE. 


GMS. 


LBS. 


12 3 4 5 6" 


8 9 10 11 12 


9530 
9070 
8020 
81C0 
7710 
7260 
6800 
6350 
5900 
5440 
4990 
4540 
4080 
3630 
3180 
2720 
2270 


21 
20 
19 
18 
17 
1G 
15 
11 
13 
12 
11 
10 
9 
8 

6 

5 






























































































































































































































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Mn 


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Fig. 28. — Chart showing the Effect of Pregnancy Upon the Weight of a Nurs- 
ing Infant. The upper line is that of the patient ; the lower one is the average line 
for the first year. 



The accompanying weight-chart (Fig. 28) illustrates this point. The 
infant did unusually well until the sixth month. As it did not seem ill, 
the parents were not disturbed until the loss had reached three pounds. 
Feeding was at once begun, and the child gradually regained its lost 
weight. It was subsequently discovered that the mother was pregnant. 



176 



NUTRITION. 



When a nursing infant has been accustomed from birth to take one 
feeding a day from the bottle, always a great convenience to a nursing 
mother, gradual weaning is generally an easy matter; otherwise it is 
sometimes an impossibility, the child refusing all food except the breast 
so long as this is given, and nothing but starvation inducing it to take 
food either from a bottle or a spoon. 

Sudden weaning may be required at any time from the development 
in the mother of acute disease of a serious nature, such as typhoid fever 
or pneumonia, of grave chronic disease, such as tuberculosis or nephritis, 
from the intercurrence of pregnancy, or from disease of the mammary 
gland. An infant should not be suckled at a breast which is the seat 
of acute inflammation. Through many of the minor ills — mild attacks 
of bronchitis, pharyngitis, indigestion, and even malarial fever — mothers 
frequently nurse their children without any seeming detriment to them 
or to themselves. In acute illness of short duration, if severe, it is 
usually better, unless we decide to wean altogether, to feed the child 
from the bottle and to maintain the flow of milk by the use of the breast- 
pump three or four times a day rather than to allow it to dry up. 



OF age 28 30 32 34 36 38 40 42 44 46 48 60 52 


26 

26 

24 

23 

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Q 

o 

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3 






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17 
16 




















































































































































































































































































































































































































































Fig. 29. — Weight Curve of a Child Properly Weaned. Abrupt weaning at eight 
months; loss of weight for the first week due to the child's being put upon cow's milk 
with low percentages. Formula: Fat 1.6 per cent, sugar 6 per cent, protein 0.80 per 
cent. Percentages were gradtialty increased, with subsequent steady and regular 
gain in weight. Weaning accomplished without the slightest symptom of indiges- 
tion. The lower is the average line. 



In cases of sudden weaning, the food should in the beginning be very 
much weaker than for an artificially fed child of the same age. The 
change can then be made without causing much disturbance (Fig. 29). 



MIXED FEEDING. 177 

When the infant has become somewhat accustomed to cow's milk the 
strength of the food may be gradually increased. 

The difficulties in weaning a child who up to nine or ten months has 
had no food but the breast are sometimes great. Much time and tact 
are necessary on the part of both physician and nurse in these cases. To 
try to teach older infants to take the bottle is unwise; feeding from 
cup or spoon is usually quite as easy. Continued coaxing of food is 
objectionable; forcing is much worse and prolongs the struggle. In 
my experience I have found the best way to offer food at regular in- 
tervals and to take it away at once if refused. This is repeated every 
three or four hours. A variety of things may be offered — modified cow's 
milk, thick gruels, beef juice, broths, bread and milk, etc. The nature 
of the food seems to make very little difference. A strong-willed child 
will often hold out for twenty-four or thirty -six hours, and occasionally 
a very stubborn one is found who will do so for forty-eight hours. At 
the end of this time the pangs of hunger are generally so acute that he 
capitulates. Serious symptoms from withholding food under such cir- 
cumstances I have never seen. 



MIXED FEEDING. 

By mixed feeding is meant a combination of nursing and artificial 
feeding. There are no objections to this practice ; on the contrary, there 
are great advantages in giving an infant only a few breast-feedings a 
day when more are impossible. This may frequently be done in hospital 
practice, and thus a single wet-nurse may assist in the feeding of several 
infants. Mixed feeding may be resorted to whenever the milk supply 
of the mother is insufficient. If at any time the mother's health begins 
to suffer, she may be relieved of night nursing or of one or more nurs- 
ings during the day, and the bottle substituted. In this way she may 
be enabled to continue lactation for some time longer than would other- 
wise be possible. Mixed feeding is often necessary during the first few 
weeks, while the mother's milk is insufficient in consequence of some- 
thing which has retarded her convalescence. For the advantage of the 
stimulation to secretion afforded by the child's nursing, it is usually 
better, rather than alternate the breast and the bottle, to put the child 
at first to the breasts. After he has emptied them, additional food may 
be given from the bottle if the baby is still hungry. The milk may be- 
come abundant and of good quality as soon as the mother is well enough 
to be up and out of doors, although it was previously scanty and of in- 
ferior quality. Two or three feedings a day from the bottle help to 
bridge over this period and prevent the child's nutrition from suffering. 
But before allowing a mother partly to nurse and partly to feed her 
infant, one should be sure that the quality of her milk is good. 
13 



178 NUTRITION. 

It is well from the very outset to accustom the infant to take one 
feeding from a bottle each day. In maternal nursing, the occasional 
feeding which is usually necessary becomes then a simple matter. If 
the child is being wet-nursed, the same plan is advisable, for it is then 
easy to put an infant upon the bottle entirely in the event of the wet- 
nurse leaving suddenly — a not uncommon occurrence. 

ARTIFICIAL FEEDING. 

There are a few fundamental principles regarding which nearly all 
podiatrists are agreed. 

Woman's milk is not only the best, it is the ideal infant food. 

Any substitute should furnish the same constituents — fat, carbohy- 
drates, protein, salts, and water, and in sufficient quantities to supply 
the needs of the body for its nutrition and growth ; x furthermore, they 
should be in about the same proportion as they exist in a good sample 
of woman's milk. 

The different constituents should resemble those of woman's milk 
as nearly as possible both in their chemical composition and in their 
behaviour toward the digestive fluids. 

1 From numerous observations, the nutritive needs of the average infant in health 
have been shown to be about 100 calories for each kilo, of body weight from the third 
week to the sixth month. These gradually diminish until at the end of the first year 
they reach about 75 to 80 calories per kilo. The caloric requirements are greater 
for very active infants on account of their more rapid metabolism; also, for premature 
infants or those much below average weight, on account of their relatively larger 
body surface to radiate heat. For such infants from 125 to 150 calories per kilo, 
may be necessary. 

An infant weighing 7 kilos. (15 pounds) requires about 700 calories daily. As the 
caloric value of a good average specimen of woman's milk is about 650 calories per 
litre, the requirements would be supplied by a little over one litre of woman's milk. 

The practical application of these facts in infant-feeding is that one should be 
careful to furnish to an infant who is artificially fed what is needed, but no con- 
siderable excess. A food much below the normal caloric requirements, or one much 
above them, may be equally improper and therefore unsuccessful. The physician 
should be able to calculate the caloric value of the food given, to see if possible where 
the mistake lies, when infants are not triving. 

The caloric value of any modification of cow's milk of known percentages may be 
calculated as follows : An infant is taking six feedings of 6 ounces, or 36 ounces daily 
of a milk containing, fat 3.5 per cent, sugar 7 per cent, protein 1.75 per cent. 
.035 (fat %) X 9.3 (cal. val. o c fat) - .325 cal. val. of fat in 1 grm. food. 

.07 (sugar %) X 4.1 (" " " sugar) - .287 " " " sugar " 1 " 
.0175 (protein %) X 4.1 (" " " protein) = . 072 " " " protein " 1 " 

.684 caloric value of 1 gram of food. 

.684 X 1000 = 684 (caloric value 1 litre food). 

36 ounces = 1.06 litres: 1.06 X 684 = 725 (No. of calories in food taken daily). 

Such calculations may be applied to any milk formula of known percentage, but 
are rather laborious. A simpler way of arriving at the same result is to multiply the 



ARTIFICIAL FEEDING. 



179 



No food except fresh milk from some other animal meets the re- 
quirements even approximately. 

In the artificial feeding of infants, cow's milk is selected as being 
the only milk available for general use. Although it furnishes all the 
constituents required, they are not present in the proportions suited to 
young infants, and the constituents are not identical with those in 
woman's milk. Cow's milk, therefore, can not be fed to most infants 
without some changes. These changes are technically known as the 
modification of cow's milk. To make these changes properly it is neces- 
sary to know what are the difficulties in the digestion of cow's milk and 
how these may be overcome. 

The earliest milk modification was simply dilution with water and 
the addition of enough cane sugar to make it taste like breast-milk. 
The only change made with the age of the child was simply to vary the 
amount of water. Instead of water as a diluent many preferred to use 
gruels made from different cereals, believing that thereby the casein was 
rendered more digestible. Upon such simple modifications as these many 
children have done, and many still do, very well, when the matter of 
dilution is judiciously managed. But it is equally true that present 
knowledge enables us to do something better. There are, however, cir- 
cumstances in which anything more complex is impossible in the way 
of milk modification. 

Later, when the composition of woman's milk came to be better 
understood, it was thought that all that was necessary in modified milk 
was to secure the exact percentages of fat, protein, sugarj and salts 
which exist in a good sample of woman's milk, and that this combina- 
tion would be the best possible substitute for it. Out of this came the 



caloric values of the different ingredients used in making up the food by the amount 
of each one that is taken. These values are approximately as follows: 



ounce 7 per cent milk 

6 " " 

5 " " 

4 a « 

3 " " 

2 " u 
1 a a 

fat-free 
whey 

milk sugar by weight 
" " " volume 
even tablespoonful of milk sugar 
ounce barley flour by weight 

" water (1 tablespoonful to a pint) 
" malt-soup extract 
" condensed milk 
" olive oil by volume 



has a caloric value of 27.5 

a u u u 25.0 

" " " " 22.5 

u u u u 200 

a a a a U5 

tt tt a tt 15Q 

a tt tt tt U5 

tt a a tt 100 

a tt u u 10Q 

tt tt tt tt 116 

tt tt u u 72Q 

" " " " 44.0 

it tt it u 100 q 

" " '.' " 2.0 

it it it U gQQ 

tt „ tt it 132i0 

tt tt tt tt 245.0 



180 NUTRITION. 

various mixtures of milk, cream, sugar, etc., which aimed to reproduce, 
according to the views of different writers, the exact proportions of 
woman's milk. This was a step in advance, in that some proper relation 
between the different food constituents was maintained. Experience, 
however, has shown that no single milk-formula can serve as a substitute 
for woman's milk; and intelligent students of the problem have ceased 
to search for one. 

In the percentage method of infant-feeding one considers the differ- 
ent elements of the food separately and tries to adapt their proportions 
to the child's digestion. While it is based upon the percentage com- 
position of woman's milk, it recognises that there are differences in the 
digestibility of cow's milk and woman's milk. It aims to discover the 
proper proportions of fat, sugar, and protein, and the best methods of 
gradational increase for healthy infants with normal digestion; and 
also to discover for those with abnormal or feeble digestion, the com- 
binations best suited to the individual conditions. Percentages are 
simply a method of stating definitely the composition of the food which 
we are giving. There is, therefore, strictly speaking, no such thing as 
the percentage method of feeding; it is merely a method of statement. 

For the fundamental work along this line we are indebted to 
Prof. T. M. Rotch, of Harvard, and Mr. C. E. Gordon, of the Walker- 
Gordon Laboratory Company. 

The calculation of food requirements of an infant in terms of calories 
is at present much employed. The requirements are assumed to be 
fairly uniform for an infant of a given weight (the figures are given 
on a previous page), and for healthy, well-nourished children this is 
approximately correct. But the calculation is not correct for those who 
are below the average weight for their ages. For such children the food 
requirements measured in calories are considerably greater than those 
allowed by the theoretical calculation. A comparison of the physiological 
requirements as calculated, with the calories furnished by the food given, 
is a useful method of control in the feeding of children who are not 
thriving or whose nutrition is especially difficult. It enables one to 
see whether he is feeding far above or far below physiological require- 
ments, and also to appreciate the necessity of increasing some elements 
in the food if others are reduced. It may be regarded as a basis of cal- 
culating food requirements, but nothing more. Like the percentage 
method, it is a method of statement; the two are not in contrast or op- 
position, and both are valuable. 

The Modification of Cow's Milk for Healthy Infants during the First 
Year. — It is absolutely necessary to consider separately the changes re- 
quired by healthy infants with normal digestion, those required by in- 
fants with feeble digestion, and those required by infants suffering from 
more or less indigestion. From a failure to make this distinction, much 



ARTIFICIAL FEEDING. 



181 



confusion has arisen. The digestion of all healthy infants is very much 
alike, and they can all be fed in much the same way ; while, on the con- 
trary, the variations afforded by unhealthy infants are almost endless, 
and each case must be considered by itself. If it is only healthy infants 
that can be fed by rule, it is equally true that if fed from the beginning 
by proper rules most infants will remain healthy. 

In adapting cow's milk for infant-feeding Ave must realise at the 
outset that, no matter how we may alter it, cow's milk is not a perfect 
substitute for woman's milk. It should not be lost sight of that there 
are inherent differences which will never be altogether removed. The 
following table gives the proportions of the various elements which make 
up the two milks: 





Woman's milk, 
average. 


Cow's milk, 
average. 


Fat 

Sugar 

Protein 

Salts 

Water 


Per cent. 

3.50 
7.00 
1.50 
0.20 

87.80 


Per cent. 

4.00 
4.50 
3.50 
0.75 

87.25 




100.00 


100.00 



These quantitative differences in the constituents are important. It will 
be seen that cow's milk has an excess of protein and salts, but is de- 
ficient in sugar. Far more important, however, for the infant are the 
qualitative differences. The sugar in the two milks, it is true, is nearly 
if not quite the same. The fat of cow's milk, however, contains a smaller 
proportion of oleic acid and a much larger proportion of volatile fatty 
acids. The salts are excessive in amount, particularly calcium phos- 
phate, but are deficient in iron and potassium. There are important 
differences in the protein. The total protein of cow's milk is nearly two 
and a half times as great as that in woman's milk. In cow's milk the sol- 
uble protein (lactalbumin, etc.) is only about one-third or one-fourth as 
abundant as the insoluble protein (casein) ; while in woman's milk the 
soluble protein forms more than half the total. But the difference in the 
digestibility of the protein of the two milks is much less than was once 
believed. Other important conditions relate to the reaction of milk, its 
freshness, bacterial contamination, etc. The modification of milk must 
aim, therefore, at something more than overcoming the quantitative dif- 
ferences in the constituents. 

In the adaptation of coav's milk for infant-feeding the emphasis 
has been at different times laid upon different elements. The view was 
long held that the chief trouble was with the protein. As a result of this 
the use of predigested milk came largely into vogue, and milk formulas 



182 NUTRITION. 

with high fat and low protein were widely employed. Then came the 
opinion prominently advanced by Czerny and Keller that it was the 
fat which produced the most trouble. More recently it has been pointed 
out by Finkelstein and his pupils that disturbances of the gravest char- 
acter may be due to the sugar and even to the salts. Our knowledge on 
this subject leaves many points still unsettled. Meanwhile, the im- 
portant thing for the student and the practitioner to appreciate, is the 
fact that any of the elements of cow's milk may cause serious disturb- 
ance. For the healthy child we are safe in emphasising that trouble is 
most likely to be due to the fat, while one with disordered digestion may 
be disturbed by any one of the elements. However, one must be care- 
ful about inferring, from the disturbances in sick infants, how healthy 
ones are to be fed. 

Fat. — The amount of fat of cow's milk which a healthy infant can 
digest varies considerably ; the usual limits are between 1 and 4 per cent. 
There are not many infants who can digest as much fat of cow's milk as 
the proportion often present in a good sample of breast-milk. "With 
most infants it is necessary to begin with as low a proportion as 1 per 
cent. The increase should be made very gradually. I have not found 
it advantageous to increase the fat above 4 per cent; for most infants 
under usual conditions the upper limit should not be over 3.5 per cent. 
I constantly see serious derangements of digestion produced by the use 
of higher percentages. 1 

The danger of disturbing the infant's digestion by fat has only 
recently been sufficiently appreciated. This mistake is frequently made 
when rich Jersey milk is employed, and also when the fat percentage 
is steadily raised for the purpose of overcoming chronic constipation. 
For nearly all infants with disordered digestion the fats must be much 
reduced. No modification of the fat of cow's milk is possible except 
in the amount. There seems to be no difference in the digestibility 
of gravity and centrifugal cream. Freshness is a very important con- 
sideration in all extra fat added to milk. 

Sugar. — In woman's milk the percentage of sugar varies but little; 
it is usually between six and seven per cent. In feeding cow's milk it 
is seldom necessary to have the sugar less than five or more than seven 
per cent. To obtain the proper proportion of sugar is the simplest part 
of the modification. It is only necessary to calculate the amount to 
be added to bring this up to the per cent desired. While, for reason? 
given elsewhere, lactose is the form of sugar generally preferred, when 
this can not be obtained, cane sugar may be substituted, but in a 
somewhat smaller amount. Besides, there is some difference in the diges- 
tibility of these two sugars. In certain forms of intestinal indigestion 

1 Archives of Paediatrics, January, 1905. 



ARTIFICIAL FEEDING. 



183 



cane sugar is sometimes better tolerated than is milk sugar. Maltose 
also may be used ; it possesses certain advantages as well as disadvantages, 
which should be carefully considered before it is employed. It should 
be distinctly understood that the purpose of adding sugar is not to 
sweeten the food, but to furnish the proper proportion of soluble carbo- 
hydrates for nutrition. 

Protein. — To the modification of the protein of cow's milk most of 
the attention was formerly given. The evidence seems conclusive, how- 
ever, that healthy infants digest this protein without difficulty. The 
main point necessary therefore is to decide upon the quantity which shall 
be given. 

During the early weeks not more than one per cent of protein is 
required. The amount should be gradually increased so that an aver- 
age child will receive at four or five months two per cent of protein 
and three per cent at eight or nine months. It is a common mistake 
to continue long with too low protein. Anaemia, malnutrition, and, I 
believe, sometimes scurvy are seen as a consequence of this practice. 
The gradual increase is therefore just as important as the low beginning. 

Inorganic Salts. — These may generally be calculated in cow's milk 
as one-fifth the total protein. When the total protein has been suitably 
reduced by dilution the amount of total salts will approximate that pres- 
ent in woman's milk. But it should not be forgotten that such dilution, 
while it brings down those salts which are in excess, chiefly calcium 
phosphate, to a proper proportion, also reduces to the same degree the 
iron and potassium which originally were not in excess. The influence 
of the inorganic salts upon nutrition is something deserving further 
study. In certain pathological conditions the salts are undoubtedly 
capable of producing serious disturbances. 

The amount of reduction obtained by the different dilutions is shown 
in the following table : 





Cow's milk. 


Diluted 
once. 


Diluted 
twice. 


Diluted 
3 times. 


Diluted 
4 times. 


Protein 

Inorganic salts 


3.50 
0.75 


1.75 
0.37 


1.16 
0.25 


0.87 

0.18 


0.70 
0.15 



Eeaction. — It has been customary to overcome the excessive acidity 
of cow's milk by adding either lime-water or bicarbonate of soda. Of 
the former, there is generally employed about one ounce to each twenty 
ounces of the food; of the latter, about one grain to each ounce of the 
food. The manner in which the addition of these substances affects the 
digestion of milk is not fully understood. The practical value of adding 
lime-water is well established by clinical experience. Some recent ex- 
periments of T, W. Clarke indicate that its chief effect may be due to 



184 NUTRITION. 

its stimulation of the secretion of hydrochloric acid. Lime-water also 
causes a retardation of coagulum formation in the stomach. 

Bacteria. — These are always present in cow's milk. They have 
been already considered in the pages devoted to the Sterilisation of 
Milk. 

The Observation of Cases of Infant-Feeding. — For the first few 
weeks it is essential that the physician see the infant every few days, 
inspect the stools, hear the nurse's report, and see how his directions are 
being carried out. When the child is well started and has begun to 
gain regularly in weight, a weekly visit will be sufficient. Still later 
a regular weekly report in writing, to be continued up to the seventh or 
eighth month, may be all that is required; after that time monthly 
reports are usually sufficient. My plan is to have the weekly report 
include only answers to certain questions, viz. : 

1. Weight: gain or loss since last report. 

2. Stools: frequency and general character. 

3. Vomiting or regurgitation — when? and how much? 

4. Flatulence or colic? 

5. Appetite: Is the child satisfied? Does he leave any of his food? 

6. Is he comfortable and good-natured and sleeping well? 

7. The formula of the food now given; quantity and frequency of 

feedings. 

8. Date. 

9. Date of last report. 

An excellent plan is to furnish the patient with printed forms con- 
taining these questions to be filled out and returned. This is a simple 
matter, and there are very few intelligent mothers who will be unwilling 
to co-operate with the physician to this extent. With information re- 
garding the points indicated, it is possible for the physician to know 
pretty accurately how the case is doing, what changes, if any, are desir- 
able in the food, and whether he ought to see the patient. It is only 
by some systematic method of observation that one can secure the best 
results with any form of infant-feeding. 

Milk Laboratories. — The first milk laboratory was established in 
Boston by the Walker-Gordon Company in 1892; one in New York in 
1893, and since that time others in many American cities. They under- 
take to furnish "modified milk" of any desired proportions, upon the 
prescription of physicians. The elements chiefly used by the Walker- 
Gordon laboratories are: (1) Cream containing 32 per cent of fat; 
(2) separated milk, from which the fat has been removed by the 
centrifugal machine; (3) a standard solution of milk sugar. 20 per 
cent strength. These contain fat, sugar, and protein in the following 
proportions : 



ARTIFICIAL FEEDING. 



185 





Cream. 


Separated milk. 


Sugar Bolution. 


Fat 


Per cent. 

32.00 
3.40 
2.50 


Per cent. 

0.05 
5.00 
3.55 


Per cent. 


Sugar 


20.00 


Protein 





By combining these it is possible to vary the percentages of fat, sugar, 
and protein in the milk to almost any degree desired, and to do this with 
very great accuracy. By using whey, a separate modification of the 
protein is accomplished; so that within certain limits a larger propor- 
tion of whey protein, chiefly lactalbumin, can be given. The highest 
proportion of whey protein with the lowest proportion of casein can be 
given when the total protein does not exceed 1.15 per cent; of this, 
0.90 per cent may be whey protein and 0.25 per cent casein. The 
alkalinity is usually obtained by adding lime-water in any desired 
amount. The laboratory adds, when requested, gruels of wheat, oats, or 
barley of any desired strength; and, finally, it delivers the milk raw, 
or heats it for sterilisation to any temperature ordered by the physician. 
The food-supply for the entire day is delivered each morning in 
the bottles from which it is to be fed. The empty bottles returned are 
washed and sterilised at the laboratory. In ordering the food the phy- 
sician simply writes for the percentages of fat, sugar, and protein which 
he desires, together with the number of feedings for twenty-four hours 
and the quantity for each feeding: 

Fat , 2 per cent. 

Sugar 6 " 

Protein 1 

Alkalinity, lime-water 5 " 

Number of feedings 8 

Amount for each feeding 4 ounces. 

Heat to 155° F., 30 minutes. 

The aim of the laboratory is to supply the physician with any milk 
modification which he may desire to use and to do this with accuracy. 

One is not restricted to any method or plan of feeding, but can 
carry out his own method with much greater accuracy than is possible 
when the milk is prepared in the average home. He is independent of 
the ignorance, carelessness, or caprice of the nurse who otherwise would 
probably prepare the food. But by whatever method the child is fed the 
physician who assumes the responsibility to direct must be familiar with 
the subject and he must keep in touch with the case if he expects good 
results. 

As a general guide to the modification of milk for an average healthy 
infant the following table is introduced, showing the manner in which 
the changes required by the development of the child may be made : 



186 



NUTRITION. 



Tabic showing percentages of fat, sugar and protein which may be ordered 

from the Milk Laboratory and are suitable for healthy 

infants for the first year. 





Fat. 


Sugar. 


Protein. 


Whey protein. Casein. 


Weak Formulas. I. 


0.75 


4.00 


0.75 


or 0.70 and 0.05 


II. 


1.00 


5.00 


0.75 


" 0.70 " 0.05 


III. 


1.00 


5.00 


1.00 


" 0.85 " 0.15 


IV. 


1.25 


5.00 


1.00 


" 0.85 " 0.15 


V. 


1.50 


5.00 


1.25 


" 0.S0 " 0.45 


Medium Formulas. VI. 


1.75 


6.00 


1.50 




VII. 


2.00 


6.00 


1.50 




VIII. 


2.25 


6.00 


1.75 




IX. 


2.50 


6.00 


1.75 




X. 


2.75 


6.00 


1.75 




XI. 


3.00 


6.00 


2.00 




Strong Formulas. XII. 


3.25 


6.00 


2.00 




XIII. 


3.50 


6.00 


2.25 




XIV. 


3.50 


6.00 


2.50 


(Whole Milk.) 


XV. 


3.50 


6.00 


3.00 




XVI. 


4.00 


4.50 


3.50 





The first group, classed as weak formulas, are designed for normal 
infants during the first few weeks, or for those with feeble digestion, 
of whatever age. 

The second group is designed for the needs of normal infants from 
about one month to four or five months, although there are many who 
can not take a stronger food for a much longer time. 

The third group is expected to cover, for children with good diges- 
tion, the period from about the fifth month to the twelfth or thirteenth 
month, gradually leading up to whole milk. 

It is important to begin with a weak formula for a young infant, 
and for one with feeble digestion, whatever its age. One may then 
gradually increase the strength of the milk according to the indications 
afforded by the child's appetite and powers of digestion. With some the 
increase can be made more rapidly than with others, but with all children 
it is important that the steps of increase should be gradual and not 
greater than are indicated in the formulas of the table ; it may even be 
desirable at times to make them more slowly than is there suggested. 
In the table the total protein to be used is indicated and also the quan- 
tities of whey protein and casein, when one desires to order these sep- 
arately. There is some advantage in so dividing the protein for very 
young or premature infants. 

Home Modification of Milk. — For the great majority of infants the 
milk is necessarily prepared at home. No plan of home modification yet 



ARTIFICIAL FEEDING. 187 

proposed secures more than approximate accuracy in the percentages of 
fat, sugar, protein, etc.; yet, if the directions given below are carefully 
carried out, a degree of accuracy sufficient for all practical purposes can 
be secured. The physician thus can not only know the percentages he 
is giving, but he can himself readily vary them within the range usually 
required, according to the indications presented. The thing desired is 
a method simple enough to be readily grasped by the average mother 
or nurse who is to carry out the physician's directions. 

The requisites for success in the home modification of milk are : 

Good raw materials — the freshest and cleanest milk obtainable. 

Knowledge on the part of the physician of at least the fat content 
of the milk and cream used in the home as it is only the fat which is 
subject to much variation. 

Directions which are clear, explicit, and in writing, that they may 
not be misunderstood. 

The co-operation of an intelligent mother or nurse, that they may 
be properly carried out. 

How to Obtain Formulas Required for General Use. — A con- 
siderable variety of formulas is required. For normal children with 
good digestion the fat should usually be higher than the protein, the 
upper limit being twice as much fat as protein. For those with dis- 
turbances of digestion, the fat should usually be lower than the protein. 
A series of formulas, with the range required, can readily be obtained 
by the method given below. Xearly all who practise home modification 
of milk purchase milk in quart bottles. 1 This has therefore been made 
the basis of calculation. If the milk used has 4 per cent of fat and 
the directions given are closely followed the results obtained will be 
very nearly accurate. 

The first step is to secure milks containing definite amounts of fat 
varying from 7 per cent down to 1 per cent. This has been described 
in detail for 4- and 5-per-cent milk in the chapter on Cow's Milk. 

It is convenient to calculate all food formulas on a basis of a 
20-ounce mixture. 

Every ounce of 7% milk in 20-oz. mixture has one-twentieth of 7, or 0.35% fat. 
" 6% " " " " " " " 6, " 0.30% " 

" " 5% "■ " " " " " " 5, " 0.25% " 

« y% " " " " " " " 1, " 0.05% " 

The percentage of protein and sugar in the various milks we are con- 
sidering differs so little that the variation may be ignored. Since 

1 If instead of purchasing milk in bottles milk fresh from the cow is used, as soon 
as received it should be strained through three thicknesses of cheesecloth or a layer 
of absorbent cotton into quart jars or milk bottles, and allowed to stand in ice-water 
or cold spring water for at least four hours. The top milk may then be removed. 



188 



NUTRITION. 



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ARTIFICIAL FEEDING. 189 

4-per-cent milk contains 4.50 per cent of sugar, each ounce of any of 
these milks in a 20-ounce mixture will have one-twentieth of 4.50 or 
0.225 per cent of sugar. Each ounce in a 20-ounce mixture will have 
one-twentieth of 3 . 50, or 0.175 per cent of protein. The figures given in 
the accompanying table will now be clear. The table shows the percent- 
age composition of the different formulas containing twenty ounces, 
which can be derived from the different milks and the manner in which 
they are obtained. It should be emphasised that in general, formulas 
from 7-, 6-, 5-, and 4-per-cent milk are to be used for healthy infants 
with good digestion ; formulas from 3-, 2-, and 1-per-cent milk are to be 
used for infants suffering from disorders of digestion. 

These formulas cover practically all our needs. This table may seem 
at first glance somewhat complicated; but it is not so if we observe that 
column A, for instance, gives the fat percentage of the food when one, 
two, three or more ounces of a 7-per-cent milk are used in a 20-ounce 
mixture; column B gives the same when a 6-per-cent milk is used, etc. 

From left to right the table would, therefore, read as follows: Tak- 
ing Formula VIII, eight ounces in twenty has 2.80 per cent of fat if 
7-per-cent milk is used ; 2 . 40 per cent of fat, if 6-per-cent milk is used, 
etc., with, in every case, 1.40 per cent of protein and 1.80 per cent of 
sugar. It will be noted that the protein and sugar percentages remain 
the same whichever percentage of fat, from 7 per cent to 1 per cent, the 
milk contains from which the formula is made up. It is thus evident 
how one may vary the fat without varying the protein and sugar. 

Thus far only the protein and fat have been considered. To secure 
the desired percentage of sugar is a simple matter. One notes first the 
percentage of sugar contained in the milk after dilution; subtract- 
ing this from the percentage desired will give the percentage to be 
added. 1 

Thus, if we use ten ounces in twenty of milk containing any of the 
percentages of fat from 7 to 1, the sugar present in the mixture is 2.25. 
To raise this to 6 per cent, one must add 3.75 per cent, or a little over 
two even tablespoonfuls, to each twenty ounces of the mixture. The 
sugar should be dissolved in the diluent before adding to the milk. 

The usual proportion of lime-water added is 5 per cent, or one ounce 
in a 20-ounce mixture; this may be increased to any desired quantity. 

The quantity of the diluent must in each instance be sufficient to 
bring the total up to twenty ounces. As a diluent for the early months 
plain boiled water is generally to be preferred. After five or six months 
barley or oatmeal water may be substituted. 

To make more than a 20-ounce mixture will be found simple if one 

1 One ounce of milk sugar by weight in a 20-ounce mixture adds 5 per cent. 

" " " " " volume " " " " " about 3 per cent. 

" even tablespoonful "" " " " " 1.75 per cent. 



190 



NUTRITION. 



calculates for 25, 30, 35 ounces, etc. Thus, for 25 ounces there is added 
one-fourth more of each ingredient; for 30 ounces, one-half more, etc. 

The Application of the Foregoing Formulas in Practice. — 
General Rules for Varying Milk Percentages. — We have indicated 
in the paragraph upon laboratory feeding a series of formulas suitable 
for the first year, and have shown how similar formulas can be obtained 
when the milk is prepared at home. A schedule like that given in the 
table is useful to indicate in a general way what percentages an average 
infant may be expected to take. But no schedule can be closely fol- 
lowed with any given child. One can not conclude that because a child 
is six weeks old he is able to digest milk containing certain percentages, 
and certain others because he is six months old. To attempt to follow 
a schedule too closely is to violate the fundamental principle of per- 
centage feeding, which is to adapt the milk to the child's requirements 
and powers of digestion at any time. In brief, one should begin with 
weak formulas and gradually increase their strength according to the 
child's needs and his ability to digest coVs milk. 

Although it is impossible to follow a schedule in regard to the com- 
position of the food for the first year, one may generally with advan- 
tage follow a schedule with regard to quantity and frequency of feeding. 



Schedule for Healthy Infants during the First Year. 



Age. 



Interval 

between 

meals, 

by day. 



2d to 7th day 

2d to 4th week 

5 weeks to 2 months 

2 to 5 months 

5 to 9 months 

9 to 12 months 



Hours. 

2 

2h 

3 

3 

3 

4 



Night 


No. of 


feedings 


feed- 


10 p.m. to 


ings, 24 


7 A.M. 


hours. 


2 


10 


1 


8 


1 


7 


1 


7 





6 





5 



Quantity for 
one feeding. 



Ounces. Grammes. 



1 -1 



'60- 45 



l£-3± 45-110 

3 -5 90-155 

4 -6 125-185 

5 -7| 150-235 
7 -9 220-280 



Quantity for 
24 hours. 



Ounces. 

10-15 
12-28 
21-35 
28-42 
30-45 
35-45 



Grammes. 

300- 450 
360- 875 
630-1,085 
875-1,300 
900-1,400 
1,085-1,400 



How and Where to Begin. — With young infants having presumably 
normal digestion it is desirable to begin with weak formulas, such as 
~No. V of C or D, with sugar raised to 5 or 6 per cent. 

The same strength should be used for a few days to test the child's 
digestion. For a healthy infant of eight pounds weight, two weeks old, 
one should begin with 2J ounces at a feeding and feed eight times a 
day, interval between feedings two and a half hours. The quantity for 
one feeding can soon be increased to 3, then to 3^ ounces. 

For a smaller or less vigorous child, one should begin with No. IV 
of C or D and give 1^ or 2 ounces at the same intervals, increasing the 
quantity, however, more slowly. 

For a healthy child with normal digestion, weaned at four or live 



ARTIFICIAL FEEDING. 191 

months, one should begin with No. VI of B or C and give a larger 
quantity, i. e., 4J to 6 ounces at three-hour intervals, and increase the 
strength more rapidly than with a younger infant. 

For one weaned at nine or ten months one should begin with No. 
VII of B or C, 6 or 7 ounces at a feeding and increase both strength 
and quantity rather rapidly. 

A stationary weight for a week or two, or even a loss of a few ounces, 
is of no importance, provided the change in diet can be effected without 
deranging digestion; for as soon as a child becomes accustomed to cow's 
milk the percentages can be raised, and progress is assured. Nothing 
is easier than to derange the digestion in the beginning by the use of 
too strong food; such disturbances, though they may not be severe, often 
continue for many weeks (Fig. 30). The closest attention is required 
in the beginning. If a good start is made, subsequent progress is easy ; 
but with a bad start there is likely to be trouble most of the time. As 
soon as an infant's capacity to digest cow's milk is ascertained, the food 
can be increased accordingly. 

Indications for Increasing the Food. — While it is important to begin 
with low percentages, it is a serious mistake to continue long with them. 
The power of digestion is strengthened by gradually increasing the work 
the organs are given to do. Abrupt increases are almost certain to 
disturb digestion. A proper rate of increase of the fat and protein is 
indicated in the table of formulas reading downward in the different 
columns. 

How rapidly the increase is made will vary much with the individual 
infant. With a vigorous child, above average weight, with good diges- 
tion, the strength may be increased rather rapidly, and also the quantity 
given at one feeding. With a small or delicate child, or one with feeble 
digestion, one must advance much more slowly both with respect to the 
strength and quantity of food. No greater mistake can be made than 
to attempt to measure the increase in food by the age of the child. We 
can not raise the percentages every week or every month regardless of 
other conditions. The progress in weight is important, yet one should 
not be guided by it alone in increasing the food. With the weak food 
necessary at first no- material gain in weight is to be expected. How- 
ever, if there is no vomiting or colic, if the child is entirely comfortable 
and sleeps most of the time, and if the stools have a normal colour 
and odour, conditions may be considered satisfactory. The food may 
be cautiously strengthened with the demands of the child's appetite, 
and soon the increase in weight will begin, and when once begun it is 
likely to continue. On the contrary, if the weight is made the chief 
concern, there is a constant temptation, when the child is not gaining as 
rapidly as the mother thinks he should, to increase the food, regardless of 
conditions and beyond his requirements, usually with the result of seri- 



192 



NUTRITION. 



ously disturbing the digestion. The best of all guides to increasing food 
is the child's demonstrated powers of digestion. If the child is not satis- 
fied and digesting well it is usually safe to increase the food. But such 
increases should seldom be made more frequently than once in three days. 
In increasing the quantity, it is not wise to add more than half an 
ounce to each feeding. During the early weeks both the quantity and 
the strength of the food should 'be increased every few days. It may be 



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Fig. 30. — Weight Curve of Artificially Fed Infant, showing the Effect of Be- 
ginning with too High Percentages. Robust child; digestion deranged when a 
few days old by beginning with fat 2 per cent, sugar 6 per cent, protein 0.75 per cent; 
food in two or three days was increased to fat 3 per cent, sugar 6 per cent, protein 
1 per cent. A good deal of indigestion resulted, and the disturbance was such that 
it was eight weeks before the digestion became normal and the gain in weight regular ; 
progress for the rest of the year satisfactory. 



difficult to tell which of these it is best to do. It is well to alternate; 
thus, when the infant requires more food, first to increase the quantity; 
then, after a few days, if still unsatisfied, to increase the strength; the 
next time, to increase the quantity again, etc. In this way will be 
avoided the error into which mothers and nurses often fall, who adopt a 
single formula and keep on simply increasing the quantity indefinitely 
whenever the child is unsatisfied. I have frequently seen infants of two 
or three months taking as much as 7 or 8 ounces every two hours, and 
even then crying from hunger. After a daily total of 32 to 36 ounces 
is reached, as happens with most infants by the fourth month, the in- 
crease in the food should be chiefly in strength; for the same child at 
eight months will rarely require more than 40 to 45 ounces. 



ARTIFICIAL FEEDING. 193 

A caution is necessar}*- against changing the formula too frequently. 
It is not possible to modify the milk in such a way as to relieve every 
trivial discomfort or disturbance an infant may have. Nurses are usu- 
ally ready to ascribe every slight symptom to the food, particularly if 
they have strong opinions of their own upon the subject of feeding, and 
are not in full sympathy with the method employed. Very often the 
cause is outside of the food and even of the organs of digestion. Unless 
some very definite symptoms of indigestion, such as severe colic, vom- 
iting, etc., are produced by the formula ordered, it is usually better to 
continue with it for at least two days, as it is hardly possible in a shorter 
time to determine what the child's digestive organs are capable of doing. 
For slight disturbances of a transient nature it is usually enough to 
dilute the food for a day or more; just before the bottle is given, one 
ounce or more of milk may be poured off and replaced by boiled water. 

Methods of increasing the Fat and Protein. — To increase the fat and 
protein at the same time, one more ounce of the milk already employed 
is added in the 20-ounce mixture. In other words, one uses successively 
No. IV, V, VI, etc., of series A, B, or C, etc. 

To raise the fat without raising the protein, gne should use the same 
number of ounces, but employ a milk with a higher fat content ; e. g., 
one is using No. VI, series D, with fat 1.20, protein 1.05. The fat is 
raised to 1 . 50, by using a 5-per-cent milk in place of a 4-per-cent milk ; 
to 1.80, by using a 6-per-cent milk; to 2.10, by using a 7-per-cent milk. 

To raise the protein without increasing the fat, a larger number of 
ounces in twenty are used, but of a milk with a lower fat content ; e. g., 
one is using No. IV, series A, fat 1 . 40 per cent, protein . 70 per cent. 
The protein is raised to 0.85 by using 5 ounces of series B; to 1.05, by 
using 6 ounces of series C ; to 1 . 20, by using 7 ounces of series D, etc. 
Although the fat in this is not exactly the same the variation is so slight 
that it may be ignored. 

Conditions determining the choice of Milk Formulas. — It has al- 
ready been stated that with a healthy young infant one should begin with 
protein of not over 1 per cent and fat of 1 . 00 or 1 . 25 per cent. With 
formulas derived as these are, from 4- and 5-per-cent milk, respectively, 
very many infants can be successfully carried through the first year by 
merely increasing the number of ounces of the milk in the formula ac- 
cording to the gradations given in the table. Most healthy infants, 
however, with the percentage of protein which we wish to give, can take 
a higher percentage of fat than is given in formulas from 4- or 5-per- 
cent milk. It is therefore advantageous and, from a point of view of 
nutrition, it is economical, to give them a higher fat percentage, such as is 
obtained by using formulas derived from 6- or 7-per-cent milk. The 
fat percentage in the food as given should not, however, be raised above 
4 per cent, and under most circumstances it is wise to stop somewhat 
14 



194 NUTRITION. 

below this. When formulas containing the higher fats, such as those 
mentioned, cause vomiting, loss of appetite, or symptoms of intestinal 
indigestion, they should be immediately discontinued and formulas de- 
rived from milks of lower fat percentage substituted. 

Children with feeble digestion or those suffering from disturbances 
of digestion should not be placed upon formulas derived from milk con- 
taining 7, 6, or 5 per cent of fat. Often with advantage they may be 
put upon formulas derived from milk containing even less fat than 
does whole milk. The special indications for such children will be con- 
sidered more fully later. 

To Reduce Milk Formulas to Percentages. — In order to appre- 
ciate the composition of any milk formula which a patient may be taking 
it is necessary to reduce this to its approximate percentages. One who 
forms the habit of making such calculations soon finds it easy, and se- 
cures a basis for comparison with the percentages given as proper for 
the average normal child. A simple method of calculation is as fol- 
lows : To determine the percentage of any constituent in the food, multi- 
ply its percentage in the original milk, cream, or top-milk by the num- 
ber of ounces of each in the food, and divide by the total number of 
ounces of food prepared. 1 

1 A patient is taking a formula composed of cream 4 ounces, milk 16 ounces, milk 
sugar 1H ounces, in a mixture containing 36 ounces. The cream is ordinary centrif- 
ugal cream, estimated to have 20 per cent fat; the milk is good average milk, estimated 
to have 4 per cent fat. 

4 X 20 = 80, which represents the fat in the cream 
16 X 4 =_64, " " " " " " milk 

144, " " " " " " total food 

144 -5- 36 (number of ounces of food) = 4, the percentage of fat in the food. 
The protein is calculated in the same way. In the illustration we estimate the 
protein of 20 per cent cream at 3.05; in the whole milk, at 3.50 per cent. 
4 X 3.05 = 12.20, which represents the protein in the cream 
16 X 3.50 = 56.00, " " " " " " milk 

68.20, " " " " " " total food 

68.20 -r- 36 = 1.90, the percentage of protein in the total food. 
In a similar way, sugar is calculated. The sugar of a 20 per cent cream may be 
estimated at 3.90; in the milk, 4.50 per cent. 

4 X 3.90 = 15.60, which represents the sugar in the cream 
16 X 4.50 = 72.00, " " " " " " milk 

87.60, " " " " " " total food 

87.60 -7- 36 (number of ounces of food) = 2.40, the percentage of sugar in the 
food before any is added. 
To add 13^ ounces to a 36-ounce mixture adds approximately 4 per cent of sugar; 
for 1.5 is 4 per cent of 36 [1.5 + 36 = .04]. 

The total sugar in the mixture therefore is 2.40 + 4, or 6.40 per cent. 
The formula contains therefore, approximately, 4 per cent of fat, 1.90 per cent of 
protein, 6.40 per cent of sugar. 



ARTIFICIAL FEEDING. 195 

Special Modifications Required by Particular Symptoms. — 
Most of the children for whom the physician's advice is sought in mat- 
ters of feeding are not thriving, or, besides, are suffering from some evi- 
dent symptoms of indigestion, and for these reasons changes in the food 
are required. In adapting milk for such cases one must rid his mind 
entirely of the notion that the food can be prescribed according to the 
child's age or even its weight, although both must be taken into account. 
The essential thing is the condition of the digestive organs, and unless 
this is carefully considered, failure is almost inevitable. To decide as 
to the proportions with which it is best to begin one must know, besides 
the age and weight, the nature and quantity of the food which has been 
taken, the appetite, the number and character of the stools, and also 
whether digestive symptoms are present, such as vomiting, flatulence, 
diarrhoea, colic, or constant discomfort. In any case the first prescrip- 
tion is somewhat in the nature of an experiment, but if the symptoms 
have been intelligently judged the experiment is likely to prove suc- 
cessful. 

Even with infants who are properly fed there are few whose diges- 
tion remains perfectly normal throughout the entire first year. Changes 
in the food are therefore necessary from time to time, even in the most 
healthy, to meet special symptoms which may arise. Many of these are 
due to disturbances of a minor character, but are none the less important, 
as they may lead to serious consequences when not immediately recog- 
nised and properly treated. 

Vomiting. — The common causes of habitual vomiting referable to 
the food are: too high fat or too high sugar, especially if the sugar is 
either maltose or cane sugar, too frequent feedings and too much food at 
one time. Frequent vomiting or regurgitation, often one or two hours 
after feeding, of curdled milk or of a sour, watery fluid, is usually an 
indication that the proportion of fat is too high. Sometimes it is the 
sugar that is in excess, and sometimes both fat and sugar are at fault. 
The first indication is to reduce the fat. Formulas from top-milk or 
milk and cream should not be used, but rather formulas from whole 
milk ; and if the vomiting is frequent, formulas from skimmed milk are 
advisable for temporary use, afterward those from whole milk. If a 
reduction of the fat does not give relief the sugar should also be reduced 
and neither maltose nor cane sugar should be used. Other changes 
which are sometimes helpful are to use twice the usual amount of 
lime-water, making this 10 per cent, or 2 ounces in each 20-ounce 
mixture. 

An infant who vomits often should not be fed at shorter intervals 
than three hours, even if only two or three weeks old. If considerable 
quantities are ejected almost immediately after feeding, it is usually 
because too much food has been given. Other causes must be considered 



196 NUTRITION. 

also — the food may be too rapidly taken, the child may be moved about 
too much, the abdominal band may be too tight, etc. 

Constipation. — The principal causes of constipation referable to the 
food are too low total solids and too low fat. Habit and general train- 
ing are also important factors. Sterilisation, and to a slight degree 
pasteurisation, cause milk to be somewhat constipating. During the first 
few weeks, if the percentages are low, there is often a species of consti- 
pation present which is simply the result of the low total solids in the 
food given. The bowels usually move every day, sometimes even twice a 
day; but the stools are often small and rather dry. Unless there is 
manifest discomfort on the part of the child, such a condition may be 
disregarded, especially if the odour and colour of the discharges are 
nearly normal. As the proportions of all the elements of the food are 
gradually increased along the general lines previously indicated, this 
form of constipation passes away. Mothers and physicians often expect 
that the bottle-fed infant will have during its first month or two the two 
or three large stools daily to which they have been accustomed with 
healthy breast-fed infants. But finding instead only one movement a 
day, and that small and sometimes dry, they resort to laxatives or 
enemata, and by their use really cause much of the trouble they are seek- 
ing to remove. 

The low fat is often the explanation of the constipation seen when 
infants are fed 'upon formulas derived from whole milk. If such 
is the case relief may sometimes be afforded by changing to formulas 
made from milk containing 6 or 7 per cent fat. The increase in the 
fat to overcome constipation can only be carried up to a certain point; 
this is generally 2.5 or 3 per cent for a young infant and 3.5 or 4 per 
cent for one who is older. If the fat is raised beyond this other dis- 
turbances of digestion, particularly vomiting, are likely to result, and 
sometimes there may even be an increase in the constipation. Some 
other means of overcoming the constipation should be resorted to. 

The substitution of the milk of magnesia for lime-water in milk 
modifications is often of service. It may be continued for several 
months without harm. One teaspoonful added to the total food for the 
day is usually sufficient; this amount may be slightly increased or 
lessened according to the effect produced. 

Milk sugar is somewhat laxative and the raising of the proportion 
of this ingredient as high as 7 per cent, if a smaller proportion is being 
used, will often be all that is needed. Maltose is much more laxative in 
its effect, and may be substituted wholly or in part for milk sugar. Its 
use will be more fully discussed later. It should not be given if there 
is vomiting. 

Colic and Flatulence. — The habitual colic of early infancy may occur 
with any form of intestinal indigestion; its causes therefore are varied. 



ARTIFICIAL FEEDING. 197 

Colic and flatulence are especially common in infants who suffer from 
constipation. Excessive flatulence may occur also when cereal gruels 
are added to the milk of young infants, particularly if the amount is 
considerable and if the cereal is insufficiently cooked. If symptoms are 
severe a reduction in all the elements of the food may be necessary. 

" Curds " in the Stools. — The undigested masses appearing in the 
stools of infants taking milk are usually spoken of as " curds." These 
may be small, soft, and white, and may make up a large part of the 
stool. An excess of mucus is usually present. Such masses are com- 
posed almost entirely of fat. There are also seen, but much less fre- 
quently, larger, smooth, hard masses of a yellowish-brown colour, but 
white on section. They are generally present in small numbers in a stool 
the rest of which may be quite normal. These are composed chiefly of 
protein, usually with an envelope of fat. Curds of the first variety, 
if numerous, call for a considerable reduction in the fat percentage. 
The smooth, hard curds, if numerous and persistent, should lead one to 
reduce the protein at least temporarily. 

Loose, Green, or Yellowish-green Stools of a Sour Odour. — These are 
sometimes due to too high a percentage of sugar, especially lactose, often 
to an excess of fat. The number of stools is usually from two to five 
daily. In appearance the stools resemble thin scrambled eggs. Stools 
such as those described are often seen in nursing infants as well as in 
those artificially fed, and the condition is not incompatible with steady 
and regular gain in weight. After it has persisted any length of time 
mucus is regularly present. 

Large, Dry, Clayey Stools. — These are often smooth, and are gener- 
ally due to an excess of fat. They have usually a peculiarly foul odour, 
owing to the presence of fatty acids. 

No Gain in Weiglit without evident Symptoms of Indigestion. — This 
is sometimes due to too weak food, all the percentages being too low, 
the child usually manifesting signs of hunger. Occasionally it is due to 
the fact that all the percentages, particularly that of the fat, are too high. 
In the latter case it frequently happens that the appetite is much re- 
duced, so that the infant takes perhaps less than half his usual allow- 
ance. A considerable reduction in the fat and an increase in the sugar, 
particularly the addition of maltose, will often lead to immediate im- 
provement. The amount used should at first be small, not more than 
two or three drachms to the day's food, and gradually increased to half 
an ounce or an ounce a day. Too frequent feedings and the practice 
of constantly coaxing the infant to take* more food, often produce the 
same aversion to food. It is much better to offer food at three or four 
hour intervals and take away the bottle as soon as the child shows that 
he does not want more. 

Modifications in the food to meet the indications afforded by more 



198 NUTRITION. 

serious conditions than those here described are considered in the later 
pages devoted to Difficult Cases of Feeding. 

The Apparatus Required for the Preparation of Milk at 
Home. — This includes a glass graduate, a glass or agate funnel, a cream 
dipper, a pitcher for mixing food, feeding-bottles, a tall cup for warm- 
ing the food, a small ice-box, and a steriliser. Other articles needed are 
lime-water, milk sugar, rubber nipples, absorbent cotton, bottle-brushes, 
borax or boric acid, bicarbonate of soda, and an alcohol lamp, or better, 
if gas is available, a Bunsen burner. The best style of bottle is that 
which can be most readily cleaned. The graduated cylindrical bottles 
with wide mouths are to be preferred. The best nipples are those of 
plain black rubber, which slip over the neck of the bottle, and are not so 
thick as to prevent their being turned inside out for cleansing. Those 
with a long rubber tube going to the bottom of the bottle should not be 
used. In many places their use is prohibited by law. The hole in the 
nipple should be large enough for the milk to drop rapidly when the 
bottle is inverted, but not so large that it will run in a stream. New 
nipples should be boiled ; but the daily boiling of nipples is unnecessary. 
It soon makes them so soft as to be useless. They should be rinsed 
in cold water immediately after using and washed daily in soap and 
water. When not in use, nipples should be kept covered in a solution 
of borax or boric acid. Bottles should first be rinsed with cold water, 
then washed with hot soap-suds and a bottle-brush. When not in use 
they should stand full of water. Before the milk is put into them they 
should again be placed in boiling water for a few minutes. 

Directions for Preparing the Food. — All the food needed for 
twenty-four hours should be prepared at one time. The first thing to be 
decided is the formula to be used ; next, the quantity of food for twenty- 
four hours with the number of feedings into which it is to be divided. 

Let us suppose, for example, that the child to be fed is a normal 
three-months-old infant weighing twelve pounds. Referring to the 
table of formulas previously given, we first decide upon the percentage 
of protein to be used; 1.20 or 1.40 per cent would seem appropriate. 
By referring to the figures in the column on the extreme left we see 
that 1 . 40 per cent of protein is obtained by using 8 ounces in 20 of any 
of the various milks. We may obtain 2.80 per cent of fat if we start 
with 7-per-cent milk; 2.40 per cent of fat if we start with 6-per-cent 
milk ; 2 per cent of fat if we start with 5-per-cent milk, etc. It is prob- 
able that such a child as that mentioned could take 2.80 per cent of fat 
without difficulty. Instead, however, of using this at the outset, a safer 
plan would be to start with 2 per cent, and later, if this was well borne, 
raise the proportion gradually to 2.40 and 2.80 per cent. A mixture 
having 2 per cent of fat and 1.40 per cent of protein is, as seen from 
the table, obtained by diluting 5-per-cent milk. 



ARTIFICIAL FEEDING. 



199 



The proper amount of sugar would be 6 per cent. The milk having 
1 . 40 per cent of protein has but 1 . 80 per cent of sugar. It is therefore 
necessary to add 4.20 per cent, to bring the proportion up to the desired 
amount. Since one even tablespoonful in 20 ounces adds 1 . 75 per cent 
of sugar, about two and a half tablespoonfuls in 20 will be needed. 

The formulas would therefore be : 





For 20 ounces. 


For 30 ounces. 


For 40 ounces. 


5-per-cent milk 

Milk sugar 

Lime water 


8oz. 

2| even tablesp'ls 
1 oz. 
11 oz. 


12 OZ. 

3f even tablesp'ls 
\\ oz. 
16| oz. 


16 oz. 

5 even tablesp'ls 
2 oz. 


Water 


22 oz. 




20 oz. 


30 oz. 


40 oz. 



Such a child as the one assumed would probably take seven feedings 
of 5 ounces each. 1 It would be well to prepare 40 ounces of food and 
have one extra bottle on hand in case of accident. 

The milk sugar should be dissolved in boiled water, which is then 
mixed with the milk in a pitcher and the lime-water added. The food 
is now divided into the seven bottles, which are stoppered with cotton. 
They are placed at once in an ice chest, or first sterilised, then cooled, 
and afterward placed upon ice. 

Directions for Feeding. — The food should be warmed to about 
100° F. before feeding, best by placing the bottle in a tall pitcher or 
cup filled with hot water, not by pouring the food from the bottle into 
a saucepan. The temperature of the food may be tested by the nurse 
with a thermometer, or by pouring a few drops upon the front of the 
wrist; it should feel warm, but not hot. The nurse should never take 
the nipple of the bottle into her own mouth. A bottle should not be 
warmed over for a second feeding. A child should not be more than 
twenty minutes in taking its food, and should not sleep with the nip- 
ple of the bottle in his mouth. It is preferable to have a young infant 
held while taking his bottle. If this is not done, the bottle should at 
least be held in such a position that the neck of the bottle is kept full, 
so that the child gets milk, and not air. It is even more necessary than 
in breast-feeding that rules as to frequency and regularity of meals be 
observed. 

The Use of other Food than Milk during the First Year. — In the dis- 
cussion up to this point nothing but the elements of milk has been con- 
sidered. Upon these alone the average healthy infant is best nourished 



1 Calculating the calories in the food offered, by the use of the table of caloric 
values already given, it will be found that the 35 ounces of food will furnish about 
510 calories, which will represent about 95 calories per kilo, of body weight 



200 NUTRITION. 

for the first four or five months. The use of the various cereals as an 
addition to the milk for young infants is a useful measure for some 
infants, but not desirable for all. The early use of much farinaceous 
food often results in serious harm. 

For the average healthy infant it is desirable to begin with farina- 
ceous food in some form by the fifth or sixth month. By this time the 
power of digesting starch is sufficiently strong for the infant to receive 
some of its carbohydrates in this form, instead of all of it in the form 
of sugar, as has been previously the case. As starch is added, the sugar 
may be gradually reduced. The form of starch used may be a gruel 
made of wheat, barley, oatmeal, or arrowroot. This will take the place 
of part or all of the boiled water in the preparation of the food. It is 
thus given with each of the feedings. By trie eleventh or twelfth month 
the quantity of the cereal may be considerably increased. 

The only other things to be advised during the first year are beef 
juice and the juice of some fresh fruit. Beef juice may be begun in the 
tenth or eleventh month, earlier with anaemic children ; at first not more 
than two teaspoonfuls daily, later the amount may be increased. The 
best fruit juice is that of the orange, which should be fresh and sweet. 
It may with advantage be given to most infants ten months old, and to 
many when seven or eight months old. Beginning with half an ounce, 
the quantity may be gradually increased to two ounces, given preferably 
about one hour before the second milk-feeding. 

The Tolerance of Healthy Infants for the Different Food Elements. — 
In the foregoing pages we have indicated the percentages which, in our 
experience, have been shown in the majority of instances to be the best 
for feeding healthy infants. However, Nature will often tolerate very wide 
variations from what is best. The desire for a rapid increase in weight 
often leads to an increase of the fat in the food much beyond the limits 
which are usually considered safe. There are some children of vigorous 
constitution and strong digestion, living under good surroundings, who 
tolerate this for a long time; some may even go through infancy to a 
period of mixed diet without any visible disturbance, and appear to 
thrive exceedingly well. There are others who bear such high fat pro- 
portions for a considerable time and then show serious disturbances. 
They thrive so long as all the other conditions are perfect; but the 
slightest deviation from these conditions, as, for example, some mild 
intercurrent illness, tonsillitis, bronchitis, etc., possibly so slight a thing 
as dentition, may bring about an acute condition which may be of a 
most alarming character. Most frequently it is the advent of very hot 
weather which is the occasion of the breakdown. There are others who 
are upset almost from the beginning if high proportions of fat are used. 
Still others gradually develop subacute or chronic disturbances of di- 
gestion and nutrition which may last for months. What is true of the 



FEEDING IN DIFFICULT CASES. 



201 



use of excessive amounts of fat is true to a less degree of the sugar and 
very rarely of protein also. One should be very cautious, therefore, in 
inferring that, because a few exceptionally strong infants thrive on 
unusual proportions or excessive amounts of some one of the food ele- 
ments, this is to be taken as a guide in feeding the average child. 

FEEDING IN DIFFICULT CASES. 

There are included under this head, infants who, owing to feeble 
digestion or individual peculiarities, do not thrive, even from the out- 
set, upon the usual milk modifications, although they may be used in- 



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Fig. 31. — Weight Chart showing the Effect of Intelligent Care. Maternal nurs- 
ing in the beginning; A, began part feeding; B, attack of indigestion; C, weaned en- 
tirely. The departure and return of the trained nurse are indicated upon the chart. 
In the interval there was constant indigestion for which no sufficient explanation 
could be found in the food. Subsequently this was discovered to be due to the care- 
lessness and neglect of the nurse. Immediate improvement on the return of the 
trained nurse without any important change in the food. It will be noticed that 
during the four and one-half months of the trained nurse's absence the net gain in 
weight was only 1 pound 3 ounces. 



telligently, and a much larger group who have prolonged disturbances 
of digestion, the result of previous improper methods of feeding. In the 
aggregate the number of children included in these two groups is large, 
and few cases in the practice of the physician cause him more trouble or 
anxiety. Even one of large experience often finds himself baffled by 
the problems which individual cases present. The difficulties are 



202 NUTRITION. 

greatest in early infancy, in cities, in institutions, in hot weather, and 
they are further increased by the existence of constitutional debility, and 
where the trouble is of long standing. That chronic indigestion in a 
young infant is a serious thing is often not appreciated. The mother 
is apt to think the problem one easy of solution; she only wants to be 
told what to feed her baby, imagining that a single food prescription 
should set the child right at once. The physician, too, sometimes regards 
the condition lightly because these infants do not seem really ill; he 
therefore considers the subject hardly important enough for his careful, 
continuous attention. What I wish to emphasise is that these cases are 
serious, that they are difficult, that in most of them nothing can be 
accomplished without close and continuous personal observation, that 
they do not tend to right themselves, and that infants' lives are often 
sacrificed as a result of bad management. 

While these infants present great variety in their symptoms, and 
must be carefully individualised in their management, there are some 
general principles applicable to all. One should begin by obtaining a 
careful history of what has been previously tried, in order to get all 
possible information respecting the type of indigestion which the child 
presents. These previous efforts in feeding should be studied with great 
minuteness; the different changes made and the effect of each one upon 
the principal symptoms, the vomiting, the stools, and the child's weight 
should be considered. With a good history obtained from an intelligent 
mother or nurse one can often at once determine where mistakes have 
been made, and in many cases the same mistake has been repeated with 
each change of food. 

A thorough investigation into the nursery routine should be made to 
ascertain not only what has been tried, but how it has been tried. It 
is frequently found that the failure is due not to any fault with the 
food prescribed, but to other conditions. The food may be improperly 
prepared or given — e. g., it may be cold or given too rapidly ; the bottles 
or nipples may be dirty ; the proper quantities and intervals not observed, 
etc. Another factor of importance is. the environment as affecting the 
nervous system of the infant. Among the well-to-do this may be the 
chief trouble. The constant or frequent excitement by visitors, or play- 
ing with a child by parents or nurses, may result not only in lack of 
sleep, but in disturbances of digestion, often in habitual vomiting, though 
the food itself is proper. Under such circumstances the removal of the 
child from its surroundings or placing it in charge of a competent nurse 
will often cause an immediate and marked improvement without any 
change in the food. Another cause of disturbance is the habitual use 
of the " pacifier," something frequently resorted to in these cases, but 
which should under no circumstances be tolerated. Success in treatment 
will depend largely upon how accurately one is able to discover the 



FEEDING IN DIFFICULT CASES. 203 

essential cause or causes of trouble and the nature of the disorder of 
digestion in the case under treatment. Without such knowledge all is 
haphazard experimentation. 

In dealing with these cases drugs are of little assistance; in most 
cases they are better omitted altogether. 

In carrying out any line of treatment little can be accomplished 
without continuous observation at fairly frequent intervals on the part 
of the physician and the co-operation of an intelligent mother or nurse. 
Particular attention should be paid to the stools, which the physician 
should see for himself, to the presence of colic or flatulence, vomiting, 
the appetite, and the body weight. A daily record is of great assistance. 
The weight, though important, is not the only guide as to progress. It 
should be taken regularly in order that a steady loss may not go on 
unnoted ; but the first signs of improvement are usually observed in other 
symptoms — the child is more comfortable, sleeps better, and suffers less 
from his special disturbances of digestion. 

Generally speaking, the intervals between feedings should be longer 
than for infants with good digestion. It is never wise to make them less 
than three hours for young infants, or less than four hours for those who 
have passed the eighth or ninth month. 

Regarding the effect upon the digestion of concentration of the food 
(i. e., a large quantity of a weak food, or a small quantity of a strong 
food), different results are seen with different children. The usual 
tendency when an infant suffers from indigestion is to dilute the food, 
and in some cases this is perfectly proper; but to continue increasing 
the dilution because the patient does not do well may be the very worst 
treatment. This may do harm by causing too much dilution of the 
digestive fluids. Small feedings, not weak food, are what benefit some 
of these children most, the balance of the daily amount of water needed 
by the child being given between the feedings. 

In very troublesome, protracted cases minor variations in the com- 
position of the food or slight changes in the plan of feeding rarely 
accomplish much. Eadical changes are usually necessary. If small 
feedings at short intervals have failed, one may succeed with larger 
feedings and much longer intervals. If very dilute food in large quan- 
tities has failed, improvement may follow much smaller feedings and 
a much stronger food. For similar reasons the most brilliant results 
are often obtained from as complete a change in the diet as possible. 
An infant who has been long on farinaceous foods is most likely to 
improve when these are stopped entirely and suitable percentages of 
cow's milk given. One whose digestion has become seriously deranged 
while taking milk, and whose symptoms have continued in spite of many 
intelligent variations' in the food, is sometimes helped by nothing so 
much as temporarily withdrawing all milk. 



204 NUTRITION. 

Clinical Types. — The greater number of these cases may be divided 
into three groups : ( 1 ) Those whose chief symptom is habitual vomiting, 
or regurgitation of food; (2) those with intestinal symptoms, most fre- 
quently with loose stools; (3) those without any marked symptoms of 
indigestion, yet whose weight is much below the average, who do not 
gain on weak food and are upset if stronger food is used. They have 
feeble digestion rather than indigestion. 

The first group, the cases with vomiting, are the least difficult of 
the three to control. The causes which produce this are usually more 
obvious and more easily removed. Altogether the most frequent cause of 
symptoms of this kind is the use of too high fats of cow's milk. The pro- 
portions used may not be improper for normal children, but they are exces- 
sive for the particular patient. A less frequent cause is high carbohydrates, 
especially foods containing maltose, sometimes cane sugar. Some of these 
children vomit only occasionally and in large quantities ; but the frequent 
regurgitation of undigested food in small quantities, often several times 
after each feeding, is more characteristic. After a time the vomitus 
invariably contains more or less mucus. Vomiting of this type is to be 
sharply distinguished from that which occurs only immediately after 
feeding from overfilling of the stomach. The symptoms also should 
not be confused with those of pyloric stenosis. Often the early mis- 
takes in feeding are not gross ones, but the gastric disturbance becomes 
established because suitable changes in the food are not at once in- 
stituted. 

In the second group, the cases with intestinal symptoms are the most 
difficult to control. Usually, if not actual diarrhoea, there are at least 
frequent stools, from three to six a day of almost every conceivable 
colour and variety, and large in proportion to the quantity of food taken. 
Mucus is almost always present; in the more severe cases and in those of 
long standing the quantity may be excessive. Exceptionally the children 
suffer from constipation. Such cases, however, are generally easier to 
manage, .as there is not the same intolerance of food ; but these patients 
may suffer from abdominal distention, flatulence, and colic. The most 
important element in the food which produces the first disturbance 
in these intestinal cases is excessive fat; frequently, also, it is due to 
excessive carbohydrates, particularly cane sugar or maltose, and some- 
times to starchy foods. Very soon, in severe cases, all the elements of the 
food, but especially fat and sugar, are badly borne. After the condi- 
tion has existed for some time it may be impossible to determine which 
of the food elements is really doing the most harm. 

In the third group, the cases with feeble digestion, mistakes in feed- 
ing are less prominent as causes. Much more important is the feeble 
constitution. This may be the result of prematurity or of congenital 
feebleness. The most striking feature of these patients is the extreme 



FEEDING IN DIFFICULT CASES. 205 

sensitiveness of their digestive organs to even the smallest deviation from 
the best methods of feeding. The slightest mistake may result in a 
serious upset, and it may be several weeks before the child is as well as 
before. Often under the best surroundings, and when fed with the 
greatest care and intelligence, such infants do not thrive. 

Management. — Passing now to the treatment of these different con- 
ditions we find that, so far as the elements of cow's milk are concerned,, 
the greatest difficulty is with the fat; this applies particularly to the 
first two groups. Next to the fat, the most trouble is with the carbo- 
hydrates. Of the sugars, maltose is more likely to disagree than cane 
sugar or starchy foods, while milk sugar is by most children the most 
easily borne. That protein causes trouble also, and how and when it 
does so, is much less evident and lacks conclusive proof. This appears 
to be true at times in very young infants. 

With these points in mind it will be evident that, for the class of 
patients under consideration, top-milk or milk and cream mixtures are 
not admissible. For nearly all of them the fat must be even lower than 
in formulas made from whole milk. According to the severity of the 
symptoms, there should be employed dilutions of 3-per-cent, 2-per-cent, 
or 1-per-cent milk, and in extreme cases even fat-free milk. It is also 
a principle of wide application that cases with predominant gastric or 
intestinal symptoms tolerate maltose badly, and in most cases cane sugar 
also. Some marked cases may be unable to tolerate more than a small 
amount of milk sugar. 

At the very outset it should be clearly borne in mind that notwith- 
standing the fact that these patients are much below normal weight, and 
often losing steadily, the treatment should be directed first of all to 
allaying the most marked symptoms of indigestion. Until these are re- 
lieved no permanent improvement can be expected. For the time being 
the weight must be disregarded. No time should be lost in attempting 
to correct the digestive symptoms by the use of drugs or the administra- 
tion of digestive ferments. Our resources for controlling these cases 
are chiefly variations in the food. 

The milk modifications which are suitable in different cases are : ( 1 ) 
Formulas from partially or completely skimmed milk; (2) buttermilk 
and other fermented milks; (3) protein milk (Eiweiss-milch of Fin- 
kelstein) ; (4) condensed milk. (Their preparation has already been 
described in the chapter on Cow's Milk.) (5) Wet-nursing; (6) sub- 
stitutes for milk. 

The variations which may be obtained from skimmed milk are suf- 
ficient for the relief of a large number of the cases met with, particularly 
those with gastric symptoms. Such an one, three or four months old, 
with symptoms of moderate severity would probably take 1 to 1.50 
per cent of protein, but not more than 0.6 to 0.8 per cent of fat. Such 



206 NUTRITION. 

formulas can be derived, as may be seen from the table, from 2-per- 
cent milk. The sugar should seldom be higher than 5 per cent. With 
improvement in the symptoms the proportion of all the ingredients may 
be gradually, but very slowly, raised ; it will usually be months, however, 
before such a patient can take as much as 2 per cent of fat. A similar 
plan of treatment will sometimes succeed when the symptoms are in- 
testinal, but in such cases one must be cautious in the use of sugar. 

Buttermilk and the other fermented milks are indicated particularly 
in cases with intestinal symptoms. Their advtantages over skimmed milk 
are that they not only have a lower fat content, but a lower sugar as well, 
and contain some lactic acid. They succeed in a certain number of cases 
that do .not respond to skimmed milk. It is seldom necessary to dilute 
them more than with an equal amount of water. 

Protein milk is indicated in cases with intestinal symptoms where it 
is desired to reduce the sugar as much as possible, but still retain a 
considerable proportion of the fat. It is not necessary to dilute this 
with more than an equal volume of water, and it may be given from 
this dilution up to full strength. In many cases with marked intestinal 
symptoms it is more efficacious than any of the other milk modifications. 

Condensed milk is the direct opposite of protein milk in that both 
the fat and the protein are low while the carbohydrate is high and chiefly 
cane sugar. It is often difficult by symptoms alone to determine the pre- 
cise indications for using condensed milk in cases with intestinal symp- 
toms, but the fact remains that in certain cases it has undoubted value. 
It may be diluted with plain water, but often its effect is better if the 
diluent is barley water. 

For the first and second groups of cases the milk of a good wet-nurse 
is seldom the best food. Its high fat content will usually aggravate the 
vomiting and increase the diarrhoea. Its use should therefore be deferred 
until the digestive symptoms are under control. At a later stage it may 
be invaluable for increasing weight. For the third group, the children 
with feeble digestion, wet-nursing is unquestionably the most successful 
method of treatment. 

The stopping of all milk is at times a useful procedure. However, 
this should be done only for a limited time, a few days to a week at 
most. The proprietary foods, under such conditions, seldom prove valu- 
able and often do much harm whether used alone or added to milk. 
Those children who have trouble with fats and sugars are sometimes 
enabled to take a sufficient amount of farinaceous food to maintain the 
body weight for some time. For such purposes a barley, wheat or oat 
gruel may be used, but it should be made strong — two tablespoonfuls of 
flour to a pint, occasionally even stronger than this. A substitute some- 
times useful is a gruel made from the soy bean. This is high in vege- 
table nitrogen and low in starch while it contains considerable fat. It 



FEEDING IN DIFFICULT CASES. 207 

may be continued as the sole diet for a short time during periods of 
marked disturbance. To any of the above substitutes milk should be 
added in small quantities as soon as possible ; at first either fat-free milk 
or skimmed milk should be employed. 

All the above resources, except feeding by a wet-nurse, are to be 
looked upon as methods of relieving digestive disturbances, not as per- 
manent foods. When the symptoms have disappeared and there is no 
longer vomiting and the stools have approached the normal, other food 
stuffs may be employed to increase weight. The most valuable one of 
these is maltose. Maltose 1 has the advantage over all sugars in point of 
easy assimilation. It has also the disadvantage in that it breaks down 
more readily than do other sugars. It should not therefore be employed 
so long as either gastric or intestinal symptoms are present. The direc- 
tions upon the package should not be followed, but the amount added 
should at first be small, i. e., one teaspoonf ul of a maltose solution or 
malt-soup extract to the daily food. This may be increased every few 
days until the total amount is from six to eight teaspoonf uls daily. If it 
causes vomiting or too frequent stools it should be omitted. 

Another valuable food stuff is olive oil. It is a form of fat which 
can at times be tolerated when the fat of cow's milk habitually disagrees. 
I have used olive oil in cases of this kind for the past two years with, in 
many instances, most striking benefit. Some children who are unable 
to take as much as one per cent of the fat of cow's milk bear olive oil 
without difficulty. The amount used at first should be small, not more 
than one-half teaspoonful three times a day. It may be gradually in- 
creased until one-half teaspoonful is given directly after each feeding, 
six or seven times a day. The maximum amount to be used for infants 
of the first year should seldom be over half an ounce daily. Only ex- 
ceptionally when used in this way does it cause diarrhoea and still less 
frequently does it excite vomiting. It is therefore of value as a form 
of fat which may be given to infants whose greatest difficulty in digestion 
is their inability to tolerate milk fat. The chief means by which weight 
can be increased in children suffering from malnutrition is therefore 
through the addition of carbohydrates, next by the addition of fat, but 
neither of these is to be employed in. any considerable quantity until 
the marked symptoms of indigestion have been controlled. As a means 

1 Many malt preparations sold in the market also contain diastase, which is not de- 
sirable for use under the conditions here considered. Loeflund's and Borcherdt's ' ' malt- 
soup extracts" are reliable but expensive. Also reliable and much more moderate 
in price are the "neutral maltose" of the Maltzyme Co., Brooklyn, and the "malt 
syrup" of the Freihofer Bakery Co., Philadelphia. Both these preparations are 
somewhat acid. To the former, five grains and to the latter ten grains of potassium 
carbonate should be added to each ounce of the malt before it is used in the food. 
All of the preparations mentioned contain from 65 to 85 per cent of carbohydrates, 
about two-thirds of which is maltose and the balance chiefly dextrin. 



208 NUTRITION. 

of allaying such symptoms nothing compares with the various modifica- 
tions of cow's milk above described. 

The use of formulas made from whey has already been referred to 
in the chapter on laboratory feeding. Whey mixtures are indicated 
whenever there is especial difficulty in digesting the casein of cow's milk. 
It may be hard to tell by symptoms when this is the case. It is more 
often true of very young infants than in those who have reached the age 
of three or four months. Such infants are frequently constipated and 
suffer in consequence from flatulence and colic. Plain whey may be 
used, or the fat may be raised by adding a small proportion of 7-per-cent 
milk (one ounce in twenty), or the carbohydrates may be increased by 
the addition of maltose. Some patients are helped very much by whey 
mixtures; very many are not helped at all for the reason that the 
trouble with such patients is not in digesting casein. 

What has just been said of whey applies also to the use of peptonised 
milk. It is employed too frequently, and is apt to be continued too long, 
and but very few of the troublesome feeding problems are solved by its 
use. Citrate of soda has been added to milk, usually in the proportion of 
one grain to the ounce of food, with the belief that a delay in the coagu- 
lation of casein in the stomach which this brings about, is a desirable re- 
sult. Neither on theoretical nor practical grounds can I see any reason 
for its use. Although I have tried it extensively I can not say that I 
have ever seen any marked benefit from it. 

The disturbances of nutrition with which the difficult feeding just 
described is associated, have been regarded by Finkelstein from a point 
of view somewhat different from the usual one. He groups infants with 
nutritional disturbances not so much according to the character of their 
stools or their previous digestive symptoms as by the way in which they 
react to food. He thus attempts to classify them on the basis of their 
functional capacity. 

A child with normal digestion and perfect nutrition has a tempera- 
ture which fluctuates within narrow limits, and he responds to a proper 
increase in food by a gain in weight. On the other hand, the response 
of the abnormal child to food is something quite different and varies 
according to the degree of his disturbance. 

In the mildest grade of nutritional disorder, that of disturbed equi- 
librium (Bilanzstdrung) , with sufficient food there is no regular gain in 
weight; but the weight fluctuates for a considerable period until more 
serious symptoms develop or until an adjustment is reached. The stools 
may appear nearly normal but the infant's tolerance of food is consider- 
ably reduced. The temperature fluctuations also are wider than are 
seen in health. 

If the condition is not relieved symptoms more definitely related to 
the digestive tract supervene, usually diarrhoea (Dyspepsie) . The stools 



HEALTHY INFANTS DURING THE SECOND YEAR. 209 

are thin, green, and contain mucus. The loss in weight for some time 
is not marked, but other symptoms are more severe and from time to 
time there is a moderate elevation of temperature. In this stage the 
child's tolerance of food is still further reduced. 

In the third degree of disturbance (Dekom position) which follows 
after a longer or shorter period there is rapid and marked loss in weight. 
The temperature is usually below normal; the pulse, slow; the respira- 
tion, often irregular, and food tolerance falls to a minimum. The 
character of the stools depends much upon the diet. When the food 
is greatly reduced the stools may appear normal, but any increase in 
food is followed by bad stools. It will thus be seen that these three 
groups of Finkelstein represent the usual types seen, viz., slight, mod- 
erate, and severe nutritional disturbances due to improper feeding. 

His chief contribution is in the emphasis laid upon the fact that 
under certain conditions the food elements, even though not in large 
amount, ma} r be injurious. They may themselves produce most definite 
and severe s} r mptoms which are in no way dependent upon bacterial 
infection. 

Finkelstein's fourth stage (Intoxication) indicates a complete break- 
down of all the processes of nutrition. This is discussed in a succeeding 
chapter. 

CHAPTER IV. 

FEEDING AFTER THE FIRST YEAR. 

HEALTHY INFANTS DURING THE SECOND YEAR. 

The physician should not relax his vigilance in the feeding of a 
child after the first year has passed. The ideas of the laity in regard to 
what a child can digest after it has outgrown an exclusive milk diet, are 
very erroneous. The majority of infants are given solid food too early, 
in too large quantities, and improperly prepared. Most of the attacks 
of indigestion during the second year are directly traceable to gross 
dietetic errors. The diet of a healthy child during the second year should 
consist mainly of milk, and some farinaceous food with bread, a small 
amount of animal food — beef or mutton, beef juice, eggs — and fruit 
juice or cooked fruit. 

Milk should be the basis of the diet. The popular idea that there 
are many children who can not take milk is an erroneous one; the real 
trouble usually is that they will not take it because other food pleases 
the palate better, and they are allowed to have their own way in this 
as in other things. It is of the utmost importance that the transition 
from a purely fluid diet to one of solid food should be made very slowly, 
and that the habit of drinking milk should not be discontinued. 
15 



210 NUTRITION. 

During the second year with average milk and average infants very- 
little modification of the milk is required. The addition of milk sugar 
is unnecessary, since the child is now able to take a considerable part of 
his carbohydrates in the form of starch. If the milk is very rich, such 
as that from a Jersey herd, it should be diluted with at least one-fourth 
water. In hot weather a still greater dilution may be necessary. 

Weaning from the Bottle. — This should always be begun by the thir- 
teenth month ; by the fifteenth month an infant should take all his milk 
from a cup, except possibly the 10 p.m. feeding, when the bottle may be 
allowed for the sake of convenience. Early weaning from the bottle is 
a matter of no small importance. Wrien the bottle is allowed to older 
children the disposition to overfeeding especially during the summer may 
be very great. Again there are many children w T ith the " bottle-habit " 
so developed that throughout childhood, although at any time they 
will take milk from the bottle, they can never be induced to take it 
any other way. 

From Twelve to Fourteen Months. — The daily schedule at this period 
should be about as follows: 

6.30 a.m. Milk, six to eight ounces; diluted with barley or oat gruel, two to three 

ounces. 
Orange juice, one to two ounces. 
Same as at 6.30 a.m. 
Beef juice, one to two ounces; 

or, the white of one egg, slightly cooked; later, the entire egg; 

or, mutton or chicken broth, four to six ounces. 
Milk and gruel in proportions above given, four to six ounces. 
Same as at 6.30 a.m. 
Same as at 6.30 a.m. 

In preparing the food, the milk and the gruel are simply mixed 
together while the latter is warm, and salt and a very small quantity of 
cane sugar added to make it palatable. It is then divided into as many 
feedings as are required for the day, each one being placed in a separate 
bottle. As to handling the bottles and pasteurising or sterilising, the 
same rules apply as during the first year. 

From Fourteen to Eighteen Months. — The diet may be increased by 
the addition of more solid food. The average child will take: 

6.30 a.m. Milk, warmed, eight to ten ounces. 
9 a.m. Fruit juice, one to three ounces. 

10 a.m. Cereal: one, later two or three, tablespoonfuls of oatmeal, honriny,. or 
wheaten grits, cooked for at least three hours; for the first month or 
two this should be strained; upon the cereal from one to two ounces 
of thin cream, or milk and cream, with plenty of salt, but without 
sugar. 
Crisp dry toast, one piece; or, unsweetened zwieback; 

or, one Huntley and Palmer breakfast biscuit. 
Milk, warmed, six to eight ounces. 



9 


A.M. 


10 


A.M. 


2 


P.M. 


6 


P.M. 


10 


P.M. 



DIFFICULT CASES DURING THE SECOND YEAR. 211 

2 p.m. Beef juice, one to two ounces; and one egg (soft-boiled, poached, or cod- 
dled); and boiled' rice, one tablespoonful, cooked four hours; 
or, broth (mutton or chicken), four ounces; one or two breakfast bis- 
cuits, or zwieback; and (if most of the teeth are present) rare scraped 
meat, at first one teaspoonful, gradually increasing to one table- 
spoonful; milk, fou~ to six ounces, if desired. 

6 p.m. Cereal: two tablespoonfuls of farina, cream of wheat, or arrowroot, cooked 
for at least one hour, with milk, plenty of salt, but without sugar; 
or, bread and milk or milk toast. 
Milk, warmed, eight to ten ounces. 
10 p.m. Milk, warmed, eight to ten ounces, which may be given from a bottle. 

From Eighteen Months to Two Years. — The amount of solid food 
may be somewhat increased. The number of the meals should be the 
same as for the preceding period. In addition, cooked fruits, such as the 
pulp of stewed prunes or baked apple, strained, may be given at the mid- 
day meal. It is generally best not to give fruits and milk at the same 
meal. Nothing but water should be given between meals. Potato is 
best deferred until the child is nearly two years old, and other vegetables 
still longer. 

DIFFICULT CASES DURING THE SECOND YEAR. 

The number of children whose nutrition is a matter of difficulty dur- 
ing the second year is much smaller than during the first year; yet the 
difficulties may be just as great. Some of these are infants who have 
been very delicate from birth, and carried through the first year only 
by the greatest effort. Others are healthy at birth, but their digestion 
has been badly deranged in consequence of improper feeding. Still others 
did well until they were weaned. The conditions may be the result of 
a severe attack of acute disease of the stomach or intestines during the 
first year. Other important causes are the early use of solid food and 
the too exclusive use of farinaceous foods of all varieties. 

Whatever the special cause of the condition, cases of chronic indi- 
gestion in the second year are to be managed along the same general lines 
as have already been laid down for those under one year. Usually the 
first thing to be done is to stop all solid food except possibly rare scraped 
beef. Starches must be greatly reduced or prohibited altogether. The 
milk should be modified as for healthy infants who are much younger 
than the patient under treatment. The daily quantity should generally 
be somewhat larger than for a young, healthy infant taking food of the 
same strength. The regular intervals of feeding should never be shorter 
than three hours, and usually intervals of four hours are to be preferred. 
A safeguard against overfeeding or underfeeding these patients is the 
determination of the caloric value of the food given. 

Striking improvement often follows the administration of rare scraped 
meat, especially to those who are over eighteen months old. From one 



212 NUTRITION. 

to two ounces may be given daily. Generally the protein in the food 
has previously been deficient. Many of these children digest meat when 
given in this way better than they do milk. Beef juice and the whites 
of eggs, partially cooked, may also be given. 

Fruits should be used with great caution. As it is with the starches 
that great difficulty is usually experienced, the carbohydrates should be 
administered chiefly in the form of milk sugar or some of the prepara- 
tions of maltose. 

When the child is once well started and gaining steadily, the food 
may be gradually increased, until the diet recommended for healthy in- 
fants of the same age is reached. All changes must be made very 
gradually, and it should never be forgotten that there is a constant dis- 
position on the part of all mothers and nurses to overfeed these children. 

FEEDING FROM THE THIRD TO THE SIXTH YEAR. 

Articles Allowed. — From the following list the diet of a healthy child 
may be arranged : 

Milk. — This should be the basis of the diet; most children require 
about one quart daily. This seldom needs modification, but if some- 
what difficult of digestion, it should be diluted. The milk should usu- 
ally be given warm. 

Cream. — This is of value, especially when there is a tendency to con- 
stipation. From two to four ounces of thin cream may be given daily. 
Above this point it should be used with caution. It should not be used 
upon fruits, especially sour fruits. It may be used upon cereals, upon 
potato, in broths, and mixed with milk. 

Eggs. — These are a valuable form of protein. They should be fresh, 
soft-boiled, poached, coddled, or scrambled, but not fried. Children vary 
greatly as regards their ability to digest eggs; most children will take 
two eggs a day, some only one, and a few can not take them at all. 

Meats. — Some form of meat should be given once a day. The best 
are beefsteak, mutton chop, and roast beef or lamb; next to these the 
white meat of chicken and certain of the more delicate kinds of fresh 
fish, which should be boiled or broiled. Beef and mutton should be 
given rare. 

Vegetables. — Potato may be given once a day, preferably baked, with 
the addition of cream or beef juice rather than butter. Of the green 
vegetables the best are asparagus tops, spinach, stewed celery, string 
beans, carrots, and fresh peas. One of these vegetables should be given 
daily — always well cooked and mashed. 

Cereals. — None of the ready-to-serve cereals should be given to chil- 
dren. They are the cause of more disturbances of digestion than almost 
any other common article of diet. Almost any cereal which requires 



FEEDING FROM THE THIRD TO THE SIXTH YEAR. 213 

cooking may be allowed — oatmeal, wheaten grits, hominy, rice, cornmeal, 
farina, and arrowroot. The most important part of the preparation is 
thorough cooking. If the grains are used, cereals should be cooked at 
least three hours, after having been previously soaked for several hours. 
They should always be well salted, and given with milk or cream, but 
with little or no sugar. 

Broths and Soups. — The meat broths are preferable to the vegetable 
broths. Nearly all varieties may be given. Plain broths are not very 
nutritious, but when thickened with arrowroot or cornstarch, and when 
cream or milk is added, they are very palatable, and at the same time a 
valuable addition to the diet. Most vegetable purees are useful, and 
when properly made very digestible. Beef juice may be used as directed 
for the second year. 

Bread and Biscuits {Crackers) . — In some form these may be given 
with nearly every meal, better without butter until the third year. All 
varieties of bread may be allowed when stale — i. e., two or three days 
old; also dried bread, zwieback, and oatmeal or Graham crackers. 

Desserts. — The only ones that should be allowed up to the sixth year 
are junket, plain custard, rice pudding without raisins, and, not oftener 
than once a week, ice-cream. Of the last three, • the quantity given 
should be very moderate. 

Fruits. — Some fruit should be given to most healthy children every 
day. Oranges, baked apples, and stewed prunes are the most to be de- 
pended upon. Raw apples should not be given in most cases. Peaches, 
pears, and grapes (with seeds removed) may be given when thoroughly 
ripe and fresh, but only in moderate quantity. Much indigestion is pro- 
duced by too much fruit or improper fruits. Special care should be ex- 
ercised in the use of fruits in very hot weather, and in cities where they 
may not always be fresh. The juice of fresh berries may be given in the 
second year; but the whole fruit should be very sparingly given to all 
young children, and always without cream. 

Articles Forbidden. — The following articles should not be allowed 
children under four years of age, and with few exceptions they may be 
withheld with advantage up to the seventh year: 

Meats. — Ham, sausage, pork in all forms, salt fish, corned beef, 
dried beef, goose, duck, game, kidney, liver, meat stews and meat 
dressings. 

Vegetables. — Fried vegetables of all varieties, cabbage, potatoes (ex- 
cept when boiled or baked), raw or fried onions, raw celery, radishes, 
lettuce, cucumbers, tomatoes (raw or cooked), beets (unless very small 
and fresh), egg-plant, and green corn. 

Bread and Cake. — All hot bread and rolls; buckwheat and all other 
griddle cakes; all sweet cakes, particularly those containing dried fruits 
and those heavily frosted. 



214 NUTRITION. 

Desserts. — All nuts, candies, pies, tarts, and pastry of every descrip- 
tion; also all salads, jellies, syrups, and preserves. 

Drinks. — Tea, coffee, wine, beer, cider, and soda water. 

Fruits. — All dried fruits; bananas; all fruits out of season and stale 
fruits, particularly in summer. 

From the third to the sixth year four meals should usually be given 
daily and at regular intervals — e. g., 7 and 10.30 a.m. ; 1.30 and 6 p.m. 
The second meal should, in most cases, be smaller than the others. 

There are a few simple rules in feeding which should always be fol- 
lowed : A child should be taught to eat slowly and thoroughly masticate 
his food. The food must always be very finely divided, for mastication 
is very imperfect even up to the sixth or seventh year. It is unwise 
continually to urge children to eat when they are disinclined to do so 
at the regular hours of meals, or when the appetite is habitually poor, 
and under no circumstances should children be forced to eat. Indigesti- 
ble articles of food should not be given to tempt the appetite when ordi- 
nary simple food is refused. Food should not be allowed between meals 
when it is habitually declined at meal-time. If a child refuses to eat, 
and examination reveals no fault with the food prepared, it should sel- 
dom be offered again until the next feeding time. In all cases of tem- 
porary indisposition, no matter of what nature, and during periods of 
excessive heat in summer, the amount of solid food should be reduced 
and more water given. If milk is the food, it should be diluted. 



FEEDING DURING ACUTE ILLNESS. 

Infants. — Feeding is an important part of the treatment of every 
acute disease in childhood, but especially so in infancy. L T nless the ill- 
ness is due to disease of the digestive tract, all cases must be fed in 
about the same way. It is much easier by proper feeding to prevent 
disturbances of digestion than to allay them. In infancy this com- 
plication often turns the scale against the patient. In every severe 
acute illness, especially if it is of a febrile character, the power of 
digestion is much diminished. One evidence of this is the onset with 
vomiting; another is the anorexia which accompanies the early stage 
of nearly all acute diseases. We should respect this disinclination 
and make it our guide in the treatment. But water is needed; with- 
holding this will often cause the temperature to rise even higher than 
before. 

In all acute febrile diseases the general rule should be. less food 
and more water than in health. For bottle-fed infants this is easily 
accomplished by simply increasing the dilution of the food ; for nursing 
infants by making the nursing time shorter and giving water freely 
between feedings either from a spoon or bottle. During febrile condi- 



FEEDING DURING ACUTE ILLNESS. 215 

tions, fat, especially, is badly borne, and this should therefore be reduced 
more than the other elements of the food. The diet should consist 
largely of carbohydrates. 

Eegularity in feeding is too often entirely ignored. While it is true 
that with some capricious children all rules must be disregarded, it is 
with the great majority a decided advantage to adhere to proper food 
and regular intervals. Food should seldom be given at less than three- 
hour intervals, although there is no limit to the frequency with which 
water may be given, and unless the stomach is irritable, almost no limit 
as to quantity. Stimulants, when required, are often best given in a 
very dilute form with the water. 

Forced Feeding — Gavage. — Not a few cases, however, are seen in 
which, after a child has been several days sick, in consequence of deliri- 
um, stupor, sepsis, or some other serious condition, it may refuse all 
food or take so little that it is in danger of death from inanition. At 
this juncture forced feeding or gavage serves an excellent purpose. 
Both food and stimulants can thus be introduced at regular intervals 
with slight disturbance, and lives saved which would otherwise be lost. 
If gavage is employed, the stomach should first be washed. The inter- 
vals of feeding should be made at least one hour longer than is cus- 
tomary in health, and usually predigested foods given. Forced feeding 
is not applicable to chronic conditions. 

Older Children. — The same conditions with reference to digestion 
exist as in the case of infants. Older patients, however, are not so 
easily disturbed, and the disturbance of digestion is not so likely to be 
serious as in the case of infants. Even here the physician should direct 
the food to be given at regular intervals, usually not oftener than every 
three hours, but should never — as is so often done — order milk to be 
given to the child every time he asks for a drink. In most cases, for 
children under five years old, milk should be somewhat diluted, usually 
with lime-water. Children who do not take milk readily may be given 
beef tea, broth, gruel, or kumyss, but rarely ice-cream or jellies so fre- 
quently prescribed, as these, if given in any considerable quantity or 
very often, are likely to disturb the stomach and take away what little 
desire for food the child may have. Raw eggs are palatable when beaten 
up with sherry, a little sugar, and cracked ice. Fruits, especially orange 
and grape juice, may be allowed in almost every febrile disease, but 
never given within two hours of a milk feeding. 

The water given may be plain boiled water, but better, in most cases, 
are some of the carbonated waters, Vichy, Seltzer, or Apollinaris, these 
being less likely to disturb the stomach. 

It is certainly a mistake to force food upon older children in any dis- 
ease in which their condition is not dangerous. But when there is sepsis, 
delirium, or coma associated with other dangerous symptoms, gavage 



216 NUTRITION. 

may be resorted to with but little more difficulty, and with no less satis- 
factory results, than in infants. 



CHAPTER V. 
THE DERANGEMENTS OF NUTRITION. 

The derangements of nutrition form a distinct and a very large class 
in the ailments of infancy, particularly during the first year. The 
symptoms are sufficiently definite and characteristic for them to be re- 
garded as separate diseases, and to be discussed as such. In adults such 
symptoms are seldom seen except in connection with organic disease. 
These cases are often very puzzling, and in a large number of them a 
diagnosis of some constitutional disease, such as hereditary syphilis, or 
tuberculosis, or organic disease of the stomach or intestines, is errone- 
ously made. At other times the symptoms resemble those of acute tox- 
aemia. The essential condition in all these cases is the inability of the 
infant to get from its food what its system needs. It can not digest or 
assimilate enough to support life. It is unable to replace from its food 
the daily waste of its tissues. The constructive metabolism is imperfect ; 
the process is, therefore, essentially one of starvation, which may be 
rapid or slow, according to circumstances. 

The fault in these cases is partly with the organs of digestion, but 
principally with the food. The problem is, to adapt the food to the 
digestion of the individual child under consideration. The solution is 
often very easy at first, but the difficulties multiply rapidly the longer 
the condition has lasted. It is therefore essential that the true expla- 
nation of the symptoms should be recognised at the earliest possible 
moment. Changes occur so rapidly in very young infants that a mis- 
take in diagnosis and a consequent delay of a few days, may be suffi- 
cient to determine a fatal result. The outcome in cases of imperfect 
nutrition depends almost entirely upon their management. The condi- 
tion is not one which tends to right itself. Spontaneous improvement 
or recovery rarely takes place. In order to recognise the condition and 
anticipate the result, nothing is so important as a close observation of 
the body-weight. A child whose nutrition is a matter of difficulty 
should be weighed regularly, in the early months at least twice a week, 
and once a week throughout the first year. If this is done, the first 
signs of failing nutrition are unerringly detected. If an infant does 
not gain in weight something is wrong; a steady loss in weight is a 
warning which should never pass unheeded; for, unless the conditions 
are changed, it is practically certain to continue, and generally with 
increasing rapidity, until the vitality has been reduced to such a point 



ACUTE INANITION. 217 

that no means of treatment can restore it. The younger the child, the 
more rapid the loss, and the longer it has continued, the greater is the 
danger. 

For convenience of description these derangements of nutrition have 
been divided into three groups, differing, however, rather in degree than 
in kind: 

1. Cases of acute inanition, which are quite rapid, generally lasting 
from a few days to a few weeks. They are rare except in young infants, 
being most frequently seen in the first three months. 

2. Cases of malnutrition, in which the symptoms are much less se- 
vere than in the other groups, although they may be of long duration. 
While it is most common in the first two years, malnutrition may be 
seen at any age. 

3. Cases of marasmus. This is similar to inanition, but a much 
slower process, lasting usually for several months. It may be seen in 
infants of any age. 

ACUTE INANITION. 

Inanition, or starvation, is a condition depending upon lack of assim- 
ilation. It is common in early infancy, when it often simulates serious 
organic disease. In older children it is not frequent, and not usually 
obscure. In all the acute diseases of the digestive tract many of the 
symptoms are due to inanition. The cases considered in the present 
chapter, however, are those in which there is no such association, or 
where the digestive symptoms, strictly speaking, are not prominent. 

Etiology. — The essential cause of inanition is that the child does not 
get sufficient food, or that the food taken is not assimilated. It usually 
develops under one of the following conditions : ( 1 ) When a child re- 
fuses all food, whether from the breast or the bottle, or can be made to 
take only an insignificant amount. The cause of this it is often im- 
possible to discover. I have seen it in a variety of circumstances, once 
in an infant five months old, previously healthy, who was suffering from 
whooping-cough. This infant utterly refused the breast, and from the 
spoon would take less than two ounces a day. After four days and 
the production of most alarming symptoms, feeding by gavagc was 
begun, and its life, I think, saved by it. Symptoms of inanition are 
sometimes seen at weaning, where a child persistently refuses to take 
food from a bottle or spoon. (2) When the food given is entirely inade- 
quate, as when an infant is nursing upon a dry breast, or one in which 
the milk supply is so scanty that the child gets practically nothing. I 
have occasionally seen it later, when the breast-milk, for some unex- 
plained reason, had suddenly failed. (3) Where the character of the 
food is improper. On account of extreme poverty, the infant may be 
getting only tea, as I have known to be the case many times. Some cases 



218 NUTRITION. 

occur in young infants who are fed entirely on starchy foods. (4) 
Where the infant at birth has such feeble powers of digestion, because 
premature or delicate, that it is unable to take or to digest sufficient food 
to maintain life. (5) When a sudden change of food is made to one so 
difficult of digestion that the child is unable to assimilate it. This may 
happen after sudden weaning. In such cases the symptoms of inanition 
are mingled with those of acute indigestion, but the former usually pre- 
dominate. 

Symptoms. — The mode of development depends upon the antecedent 
condition. In young infants inanition often follows malnutrition where 
perhaps there has been nothing noticeable except a gradual loss in 
weight; or if the weight has not been watched, it may be observed only 
that the infant has not been doing well. Severe symptoms may come on 
quite suddenly, and if the nature and the gravity of the condition are not 
appreciated the case may terminate fatally in two or three days. The 
loss in weight is now rapid, amounting often to three or four ounces a 
day. The temperature in the newly born may be high, but it is more 
often subnormal. The pulse is always weak and rapid. The urine is 
scanty and very low in chlorides and often contains acetone. The ex- 
tremities are cold, and the peripheral circulation poor. There is usually 
complete muscular relaxation, almost collapse. The skin may be dry 
or covered with a clammy perspiration. There is extreme pallor, and 
often there is cyanosis. This is always a grave symptom, and when it is 
marked the case usually ends fatally. Cyanosis may be present in chil- 
dren who have previously cried well and in whom there is no suspicion 
of atelectasis. The respirations are rapid and may be irregular. There 
may be constant worrying and fretfulness, or a condition of semi-stupor, 
in which the child makes no sign of wanting food. The fontanel is 
sunken and the pupils are contracted. The stools contain undigested 
food. The bowels usually move frequently, although there may be con- 
stipation, clue to the small amount of food taken. When all food is 
refused for two or three days the stools ma} 7 resemble meconium. While 
no desire for food is manifested, infants will sometimes swallow food 
when it is offered, retaining everything given for several feedings, when 
the whole quantity is vomited. 

The course of the disease depends much upon the age of the infants. 
Those under one month succumb most quickly. In them the symptoms 
sometimes last but two or three days, seldom more than a week or ten 
days, the children simply drooping steadily until death occurs. With 
proper treatment complete recovery may take place in a week. In 
older infants the progress, whether upward or downward, is usually less 
rapid. 

Prognosis. — The outcome of these cases is always uncertain. In few 
conditions is it more so. It is hard for one who is not familiar with the 



ACUTE INANITION. 219 

condition to appreciate the great and even the immediate danger in 
which a young infant may be from inanition, notwithstanding the absence 
of both vomiting and diarrhoea. It is difficult to estimate the gravity 
of an individual case except after twenty-four hours 7 observation. The 
best of all guides is perhaps the weight. Where the loss is several ounces 
each day the chances of recovery are small. The presence also of fre- 
quent vomiting or of diarrhoea makes the outlook very bad. A high 
temperature, very marked relaxation, copious perspiration, cold extrem- 
ities, and cyanosis are all bad symptoms. 

Diagnosis. — Inanition is distinguished from malnutrition by its 
greater severity, and from marasmus by its more acute character. The 
usual mistake is that of confounding inanition with some local or consti- 
tutional disease. It may be mistaken for acute indigestion, meningitis, 
gastro-enteritis, pneumonia, or septicaemia. The temperature when ele- 
vated is especially likely to mislead. 

Treatment. — The existence of inanition in young infants presupposes 
only the feeblest powers of digestion and assimilation. If possible, a 
good wet-nurse should be secured, for in most of the cases the time for 
action is so short that there is no 'opportunity to experiment with arti- 
ficial feeding. 

The breast-milk should usually be diluted, at first with an equal vol- 
ume of water or lime-water, and the quantity should be only a few 
drachms. It may be given with a spoon, a medicine-dropper, or a Breck 
feeder. If there is vomiting or diarrhoea, the milk should be pumped 
from the breasts, and the cream removed, since the high fat of good 
breast-milk is not well borne. Gradually the quantity and strength of 
the milk are increased until the child is allowed to take the breast 
in the usual manner. 

When no wet-nurse can be obtained, the artificial food should be low 
in fat and protein and relatively high in carbohydrates. Formulas such 
as are desired may be obtained from whole milk. The fat and protein 
should be from 0.50 to 1 per cent and milk sugar, 4 or 5 per cent, 
and in addition maltose may be added to bring the total carbohydrate 
up to 7 per cent. A 5-per-cent solution of milk sugar may be given with 
egg albumin; or condensed milk may be tried. The quantity given 
should be small and the frequency not oftener than every two hours. 
When food is not readily taken, it may be given by gavage. Eectal feed- 
ings may be of some assistance for a short period. 

Often the symptoms are due quite as much to a lack of water as to a 
lack of food. Injections of a normal salt solution may be given per 
rectum or even under the skin with very great advantage. Eectal 
injections should be given at 104° to 110° F. and carried high into 
the colon by a catheter; they should be repeated every four or five 
hours. 



220 NUTRITION. 

In extreme cases the slow and continuous rectal saline injection 
known as the Murphy method may be employed. 

The other treatment required by these cases is the reduction of high 
temperatures by sponging or tepid baths, and the raising of subnormal 
temperatures by electric pads, hot-water bags, and wrapping in cotton. 
Stimulants are indicated, but are not very well borne; alcoholic prepa- 
rations by the mouth often excite vomiting, but by the rectum they may 
be better tolerated. Drugs are of no use whatever. 

Inanition in older infants is seldom serious unless it follows some 
acute illness. Peptonised milk b} T gavage is often useful. There are 
some patients, usually over a } T ear old, who refuse fluid food of every 
description, and vomit it when it is coaxed or forced, yet who will take 
and digest in a most surprising manner some form of solid food, such 
as beef-steak, oatmeal, bread, crackers, or even potatoes. For the time 
one must give whatever the child will take, and gradually change to a 
suitable diet as soon as circumstances will permit. The needed water 
may be given per rectum. 

All children who have suffered from acute inanition need the closest 
attention for a long time, particularly as to their feeding, regarding 
which suggestions will be found in the pages devoted to Infant Feeding. 

MALNUTRITION. 

Cases of malnutrition are exceedingly common, and occupy a large 
part of the time and attention of one engaged in practice among chil- 
dren. Although these children can not be said to be actually ill, they 
are very far from well, and their condition is often the cause of the great- 
est solicitude on the part of parents, not only from the existing state of 
health, but from the apprehension of the development of some serious 
organic or constitutional disease, especially tuberculosis. 

Etiology. — Malnutrition may depend upon inherited conditions. 
Certain children are delicate from birth, possessing only feeble vital- 
ity, though without giving evidence of any actual disease. They are 
often the offspring of parents of delicate constitution and poor phys- 
ical development, or of those with tuberculosis, gout, syphilis, or alco- 
holism. Very many city children are included in this group. Among 
the poor the condition is the result of bad hygiene, insufficient or 
improper food, overcrowding, etc. Among the well-to-do it is seen 
in those who inherit a too highly developed nervous organisation with 
a corresponding amount of physical deterioration. Another group 
includes those children who were premature or very small at birth, 
weighing perhaps only three or four pounds. Many cases are trace- 
able to improper feeding or equally poor nursing during the first few 
months. These children get a poor start in life, and on that account 



MALNUTRITION. 221 

are handicapped throughout infancy. A frequent cause of malnutrition 
in infants is the pernicious custom of keeping them in close apartments 
where the thermometer ranges from 72° to 78° F., and where the 
greatest anxiety is constantly felt lest they take cold. Such infants may 
lose in weight, become anaemic, and exhibit all the signs of malnutrition 
where nothing else is wrong except the conditions mentioned. Malnu- 
trition often depends upon some previous acute disease, especially of the 
stomach and intestines. 

In children who are over two years old the condition of malnutrition 
may be due to any of the factors above mentioned — inherited feebleness 
of constitution, bad feeding and its resulting indigestion, too little fresh 
air, and close confinement indoors. It is, however, at this period much 
more frequently than in infancy, dependent upon some previous acute 
disease. As a result, an impression is left upon the child's constitution 
which lasts for months, often for years, and which manifests itself not 
by any special local symptoms, but by a general condition of debility 
or malnutrition. Sometimes such diseases, instead of being directly the 
cause of the symptoms, are the occasion which brings out some latent 
inherited taint or constitutional weakness in children who up to this 
time, perhaps, have appeared exceptionally healthy. In other cases mal- 
nutrition depends upon faulty methods in education, especially upon 
overpressure in schools. 

Symptoms. — In Infants. — The weight is much below the average, and 
is either stationary or the gain is very slow, often only five or six ounces 
a month at a period when it should be from one to two pounds. A 
child under my care weighed at fourteen months but eight and a half 
pounds. This infant at birth weighed three and a half pounds, but in 
a few weeks the weight dropped to two pounds. 

Not only the weight but the general physical development is much 
below the normal. At one year the body length may be three or four 
inches less than the average. Dentition is usually but not always de- 
layed. Muscular development, too, is backward; many of these chil- 
dren do not sit alone until a year old, and barely walk at two and a half 
years. The muscles are soft and flabby, and the ligaments so weak that 
paralysis is often suspected. The body is so small that the head seems 
unnaturally large, and a diagnosis of incipient hydrocephalus is fre- 
quently made. Mentally these infants are often quite up to the average. 
Some symptoms of rickets may be present, but often there are none. 

The examination of the blood reveals the usual changes of secondary 
anaemia which varies much in degree, being rarely extreme. The circu- 
lation is usually poor, the hands and feet are frequently cold. In many 
children the skin is unnaturally dry; in others there is a disposition to 
excessive perspiration, particularly about the head. Nervous symptoms 
are usually present. These children are restless, fretful, and irritable; 



222 NUTRITION. 

they sleep badly during the day, and often worse at night. Enlargement 
of the lymph glands is common, especially those of the neck. The cervi- 
cal adenitis may have started from a slight catarrhal cold, but the glands 
continue to swell after this has subsided and may remain enlarged for 
months. 

One of the most characteristic things about these infants is their 
feeble power of digestion and assimilation. Unremitting care and con- 
stant watchfulness are required to keep them up to even a moderate 
standard of health. The most trivial changes in food may upset them. 
Attacks of acute indigestion are usually brought on by overfeeding — the 
mistake which is almost invariably made by mothers who are discouraged 
with the slow progress made, and are anxious to make their children 
grow fat and strong. The balance is so delicately adjusted that the 
slightest deviation from proper rules of feeding, either as to the quality 
of the food or the quantity given, is immediately followed by an attack 
of acute indigestion, often by severe diarrhoea. As a result, the child 
may lose as much in two or three days as it has gained in a month or 
more. These acute attacks, if in summer, not infrequently prove fatal. 
Not only do these patients have but little resistance to acute disturbances 
of the stomach and intestines, but any acute disease is serious — measles, 
whooping-cough, and pneumonia being especially fatal. 

Among the poor or in institutions, cases of malnutrition like those 
described, if in children under nine months old, are almost certain to go 
on from bad to worse until they have reached the condition described 
as marasmus. Between this and malnutrition no sharp distinction can 
be drawn; they are rather different degrees of the same general process. 
In private practice, where it is possible to have the best care and sur- 
roundings, with the co-operation of an intelligent mother or nurse, a 
very large number of these infants can be reared. After the second year 
has passed the problem becomes a much simpler one, and if infectious 
diseases and other forms of acute illness can be avoided, the probabili- 
ties are in favour of the child's becoming stronger each year and growing 
to maturity. 

In Older Children. — In general appearance these children are thin, 
pale, and undersized, particularly if the condition is constitutional or 
hereditary. Sometimes they are taller than the average for their age, 
and their symptoms are often attributed to too rapid growth. One of 
the most striking things about children suffering from malnutrition is 
their vulnerability. They " take " everything. Catarrhal processes in 
the nose, pharynx, and bronchi are readily excited, and, once begun, 
tend to run a protracted course. There is but little resistance to any 
acute infectious disease which the child may contract. One illness often 
follows another, so that these children are frequently sick for almost an 
entire season. Their muscular development is poor, they tire readily, 



MALNUTRITION. 223 

are able to take but little exercise, and their circulation is sluggish. 
Mentally they are usually bright, often precocious. Many belong to the 
group of nervous children. They are cross, fretful, and any unusual 
excitement produces an effect which lasts for some time; for example, 
after a children's party or a Christmas tree they may lie awake half 
the succeeding night, and may be really ill for two or three days. Their 
sleep is usually disturbed and restless; they waken frequently, and occa- 
sionally suffer from night-terrors. At a later age they are favourable 
subjects for chorea, neuralgia, and all functional nervous disorders. 

Digestive s}miptoms, if not constant, are very easily excited. In fact, 
they do not suffer so much from chronic indigestion as from a delicate or 
feeble digestion, which is easily upset by the slightest deviation from 
the regular routine. Children of five or six years have to be fed as care- 
fully as infants of eighteen months or two years. The appetite is usu- 
ally poor, and mothers are distressed because their children eat so little, 
yet, when food is urged upon them, attacks of indigestion follow with 
singular uniformity. The tongue is slightly coated the greater part of 
the time. The bowels are apt to be constipated, apparently more from 
lack of muscular tone than from anything else. From time to time, 
from slight causes, such as exposure to cold, or even from fatigue, there 
may be large quantities of mucus in the stools for two or three days at 
a time, although this is not a prominent feature of most of these cases. 
When they are not fed with the greatest care these children suffer con- 
stantly from indigestion. A moderate amount of anaemia is always 
present, and this may be the most striking feature. 

The duration of the condition depends very much upon the cause. 
If the cause is constitutional or inherited, it is likely to last throughout 
childhood, but it often greatly improves about the time of puberty. Where 
it follows some acute illness it commonly lasts for a few months only; 
but the effect of an acute attack of broncho-pneumonia or of ileo-colitis 
may continue for years. If the malnutrition is the result only of the 
child's surroundings, like the confinement incident to city life, very 
rapid improvement may follow a removal to the country. In some chil- 
dren marked improvement is seen about the seventh year; in others, a 
great change comes at puberty". 

Diagnosis. — The physician should not be too ready to make a diag- 
nosis of simple malnutrition. Before accepting such a diagnosis, he 
should examine the child with the greatest care, to exclude the com- 
mon organic and constitutional diseases. Much regarding inherited con- 
stitutional tendencies can be learned from the family history and from 
the condition of other children in the family. In the first place, tuber- 
culosis must be excluded by a study of the temperature and physical signs 
rather than by the tuberculin test. This often gives a positive reaction 
when no other evidence of this disease exists and when none develops 



224 NUTRITION. 

subsequently. It is in such cases extremely doubtful whether the latent 
tuberculous focus plays any part in the production of the symptoms. 
Other things to be considered are syphilis, rickets, chronic malarial 
poisoning, diseases of the blood, intestinal parasites and of course organic 
diseases of the lungs, heart, stomach, intestines, liver, and kidneys. Even 
malignant disease, though rare, should not be overlooked. It may take 
careful observation for several days, and sometimes for weeks, with 
repeated physical examinations, before all these conditions can be posi- 
tively excluded. 

The next step in the diagnosis is to discover upon which one of the 
many possible causes malnutrition depends. In private practice the 
great proportion of cases are due to improper feeding or nursing; next 
in importance are improper surroundings; and last come inherited con- 
stitutional conditions. In other words, most of these children are born 
healthy, but become ill or delicate in consequence of improper manage- 
ment. 

In older children, after excluding constitutional and local diseases, 
the whole life of the child must be investigated to discover the funda- 
mental condition which is at fault. A carefully obtained history from 
infancy is of the greatest assistance. It is often difficult, and some- 
times impossible, to get at the primary factor, for in cases of long stand- 
ing there may be symptoms connected with almost every function of the 
body. One should scrutinise closely the quality and quantity of food 
given, the amount of sleep, the hours of study and recreation, the 
amount of exercise in the open air, and the physical conditions surround- 
ing the child. Usually the most important factor in the case can be 
discovered. 

Prognosis. — This depends much upon the cause of the condition; if 
it is one that can be removed, the prognosis is good not only for im- 
provement but for complete recovery. The longer the condition has 
lasted and the greater the general disturbance the slower will be the 
improvement. The great danger is the supervention of some acute dis- 
ease while the child's resistance is so greatly reduced. Acute indigestion, 
gastro-enteritis, and broncho-pneumonia are especially to be dreaded. 

Since everything depends upon the fidelity with which directions as 
to diet and general management are carried out, the cases which present 
the greatest difficulties are those in which these conditions are hardest 
to control. When a child is not only suffering from malnutrition, but 
has been indulged and spoiled in every way by anxious but unwise par- 
ents, no success is to be expected unless the child can be placed in the 
hands of an experienced and trustworthy nurse. Cases due to improper 
feeding or to bad surroundings usually improve when these are cor- 
rected, and the worse these conditions have previously been the greater 
the improvement to be expected. Those depending upon an inherited, 



MALNUTRITION. 225 

delicate constitution are not so hopeful, and require the closest attention 
throughout childhood. 

Treatment. — This is a problem of nutrition to be solved by diet and 
general management, drugs occupying a very small place. 

In Infants. — In very young infants treatment is chiefly a question of 
feeding. This should be carried on according to the rules given in the 
chapter upon Feeding in Difficult Cases. These children often do fairly 
well during the first year, but after this time frequently do very badly, 
on account of the failure to appreciate the fact that, although over 
twelve months old, in point of development they resemble healthy in- 
fants of four or five months, and are to be managed as such. If they 
are nursing, weaning should often be deferred until the sixteenth or 
eighteenth month, or at least partial nursing should be continued until 
that time. When cow's milk is begun it should always be very largely 
diluted, usually modified as for* a healthy infant a few months old. 
Very rarely a child is met with who has an idiosyncrasy as regards 
cow's milk and can not take even the smallest amount without marked 
disturbance. I have seen a single feeding in which one ounce of milk 
was given, and that diluted three times, produce a violent attack of 
acute indigestion which proved well-nigh fatal. Feeding during the 
entire second year should l>e carried on very much as in ordinary healthy 
children from the sixth to the twelfth month. A deviation from this 
rule almost invariably results disastrously. One must be guided as to 
the amount and character of the food, not so much by the child's age as 
by his digestive capacity, and in most cases this is much feebler than 
the mother or even the physician supposes. In many of these cases, 
cow's milk — for them the most valuable of all foods — has been excluded 
from the diet, when the only trouble is that it has not been given in 
sufficient dilution. For some children it may be partially peptonised 
during periods when digestion is especially feeble. 

Next in importance to diet is fresh air. Often these patients will 
not improve with any variation in diet until fresh air is secured. Then 
increased digestive power is seen in the course of a few weeks, some- 
times in a few days. The natural tendency of a mother who has a 
delicate infant, or one suffering from malnutrition, is to house it closely 
and never allow it a breath of fresh air. It is of the greatest assistance 
if these children can be sent to a warm climate for the winter. If this 
is not possible, fresh air may be obtained by changing apartments, or 
by an airing in the room with the windows open. In the beginning 
this should be done for a few minutes only, the time being gradually in- 
creased to two or three hours each day. The child should be clothed 
as for the street, and, if necessary, hot bottles should be placed at the 
feet. 

Cold sponging is another valuable tonic. After the morning bath is 



226 NUTRITION. 

given, at 95° F., the entire body should be sponged for a moment only, 
with water at a temperature of 60°, or even 55° F. This produces a 
certain amount of shock and causes loud crying, which is of itself 
beneficial. How frequently this should be done will depend upon the 
reaction following it. If the child remains blue and cold for some time 
afterward, the cold sponging should not be repeated. If there is a good 
reaction, it may be used daily. 

Friction and massage are useful in many cases. The child should be 
laid upon the lap of the nurse, if possible before an open fire, and should 
always be covered with a blanket. The entire body should then be rubbed 
for ten or twenty minutes with the bare hand, or, better, with cocoa 
butter. Simple rubbing may be used, or the movements of massage em- 
ployed. If the latter, they should be very gentle at first, and only for 
a short time. Professional operators are inclined to be too energetic 
for little children. There is no advantage in rubbing with cod-liver oil 
instead of cocoa butter, while the odour makes it decidedly objectionable. 

The only tonics I have found of much value are iron, nux vomica, 
and cod-liver oil. Nux vomica may be given alone or with wine. Cod- 
liver oil is too much used in these cases, and in too large doses. Many of 
these infants can not take it at all. It should rarely be given when the 
tongue is coated and the appetite very poor. The dose should always be 
small, e. g., ten drops of the pure oil three times a day, or twice as much 
of an emulsion. Olive oil in many cases is better borne and quite as 
efficacious; it may be given in half or teaspoonful doses three times a 
day. 

The secret of success in treating cases of malnutrition is, to hold the 
patient to a regular routine in feeding, sleeping, and in everything relat- 
ing to his life. Experiments are nearly always unfortunate. The physician 
should lay down in writing, for the guidance of the mother, specific rules 
with regard to the amount of food, the time at which it is to be given, 
the hours for bathing, sleep, and airing. He should see the patient at 
regular intervals and often enough to be sure that his orders are being 
enforced. Good results are obtained only by constant watchfulness, and 
although improvement may not be seen at once, it is in most cases sure 
to come if the mother will co-operate. In my own experience no class 
of patients have given me so much satisfaction as cases of malnutrition 
in infancy. 

In Older Children. — The same general principles are to be applied 
to them as to infants. The diet is of the first importance. Only the 
simplest, plainest, and most easily digested articles of food should be 
given. The problem is to secure the maximum nutritive value in the 
food with the minimum tax on the digestive organs. Milk, beef, eggs, 
the lighter and more easily digested cereals, bread, and fruit should 
form the diet. All sweets, pastry, highly seasoned food, candy, nuts, tea, 



MARASMUS. 227 

and coffee should be absolutely prohibited, and, in fact, all the articles 
mentioned as " forbidden " in the chapter on the Feeding of Older Chil- 
dren. When the appetite is poor and simple food not well taken, the 
child should not be allowed to take indigestible articles for the sake of 
eating something. Nothing should be given between meals, and regular 
hours of feeding must be followed. Usually I have found three meals 
a day, for children over three years old, better than the practice of giv- 
ing more frequent feedings. But this is not always the case. Under 
no circumstances should children be coaxed, urged, or hired to eat; 
much less should they be forced to do so. There is a popular misap- 
prehension in regard to the variety in diet which children need. Most 
cases do better when a very simple and fairly uniform diet is continued. 

The nervous factor is a very large and a very important one. Many 
of these children are essentially cases of neurasthenia at as early an 
age as four or five years. Excitement and activity are what they crave 
and what must be most carefully avoided. 

The general habits of children should be directed; there should be 
regular and early hours for retiring, freedom from undue excitement, 
and interest should be awakened in out-of-door amusements. A pony or 
dog will be found useful. Children should be kept as much as possible 
in the open air, but the amount of active exercise should be strictly 
limited. Usually they do much better if they can be in the country 
during the entire year. Only a limited amount of reading and study 
should be allowed; and if children are at school, care should be taken 
that overpressure is not the cause of the symptoms, particularly in an 
ambitious child. The cold sponging given in the morning, as described 
in the introductory chapter on General Therapeutics, is extremely bene- 
ficial to children who take cold readily. Massage is useful for the benefit 
which it affords to the chronic constipation which is so frequently a 
symptom of malnutrition. 

Of the tonics, iron, arsenic, and cod-liver oil are required in most 
cases, and the amount and combination may be varied from time to time, 
with the season of the year and the condition of the child's digestion. 
In general, these children require early hours, a simple diet, a quiet, 
regular life, and very little medicine. 

MARASMUS. 

(Infantile Atrophy; Simple Wasting.) 

Wasting is a symptom of many conditions in infancy. It occurs in 
tuberculosis, in infantile syphilis, and also as a result of acute or chronic 
disease of the stomach and intestines. Cases of wasting dependent upon 
such causes are not included in this chapter. 

Marasmus is the extreme form of malnutrition seen in infancy, oc- 



228 NUTRITION. 

curring, so far as is known, without constitutional or local organic 
disease. It is a vice of nutrition only. 

Etiology. — Marasmus is not very often seen in the country or in 
private practice; but it is frequent in dispensary practice in all large 
cities, and is especially common in institutions for young infants. In 
my own experience in four institutions, more than one half the deaths 
under one year were directly or indirectly from this cause. Marasmus is 
a very large factor in the immense infant mortality of large cities in 
summer. Although the cause of death is usually reported under some 
other name, the determining factor in the fatal result is the previous 
marantic condition of the patient. The primary cause may be a con- 
genital weakness of constitution which may depend upon heredity. It 
is often seen in premature children and in the illegitimate offspring 
of girls of sixteen or eighteen. In the vast majority of cases, however, 
it depends upon two factors — the food and the surroundings. Among 
the poor who live in tenements, infants who are artificially fed almost 
invariably do badly. This is due to ignorance in regard to the proper 
methods of infant feeding and inability to procure what the child re- 
quires, especially pure cow's milk. A country infant may be neglected 
in many respects, and is often badly fed; but he has plenty of pure air, 
and usually thrives. In the city, as long as an infant has a plentiful 
supply of good breast-milk he continues to do well in most instances, in 
spite of the fact that his surroundings are bad. When there are not only 
bad feeding and unhealthful surroundings, but also an inherited con- 
stitutional vice, we have all the factors required to produce marasmus 
in its most marked form. The odds are so against the infant that the 
feeble spark of vitality flickers for a few months only and gradually 
goes out 

Another prominent factor in the production of marasmus is the 
overcrowding of infants in institutions. Even though artificially fed 
after the most approved methods, I have seen scores of infants who were 
plump and healthy on admission lose little by little, until at the end of 
three or four months they had become wasted to skeletons — hopeless 
cases of marasmus, dying of some mild acute illness, such as an attack 
of indigestion or bronchitis, the essential cause, however, being maras- 
mus. The common mistake is that of placing too many children in one 
ward, with no chance of obtaining a proper amount of fresh air. No 
house-plant is more delicate or sensitive to its surroundings than is an 
infant during the first few months of life. 

Lesions. — The post-mortem findings in cases of marasmus are ex- 
ceedingly unsatisfactory, and throw little if any light upon the disease. 
Every now and then general tuberculosis is discovered in patients dying 
apparently of marasmus, the existence of which was not previously 
suspected. An occasional lesion is fatty liver. This may lead to such 



MARASMUS. 229 

enlargement of the organ that its weight is increased by one half. Both 
to the naked eye and under the microscope the usual changes of fatty 
infiltration are present, often to an extreme degree. In the past too 
much has doubtless been made of this condition of the liver in maras- 
mus. From figures given elsewhere (see article on Fatty Liver), it 
will be observed that the lesion is not more frequent in this condition 
than in infants dying from other diseases. The most marked examples 
are seen in cases of marasmus which have lasted for seven or eight 
months. Its exact relation to the condition of wasting has not yet been 
determined. 

With these exceptions the autopsies show nothing striking, and I 
have had the opportunity to make at least two hundred of them. The 
lesions usually found are the following : The brain is commonly anaemic, 
with dark fluid blood in the sinuses, marantic thrombi being rare. A 
strip of hypostatic pneumonia, from one to two inches wide, may be 
seen along the posterior border of both lungs, involving the lung to the 
depth of half an inch, or less. In the younger infants there are fre- 
quently areas of atelectasis in the lower lobes. The pleura is almost 
invariably normal. The heart is pale, with perhaps a slight increase in 
the pericardial fluid. The spleen and kidneys are pale, but otherwise 
normal. The stomach may be dilated ; the mucous membrane is usually 
pale, often coated with tenacious mucus. The intestines contain undi- 
gested food, sometimes mucus. The solitary follicles of the colon and 
small intestine, and sometimes Fever's patches, are slightly enlarged, 
the mucous membrane in other respects being normal. The mesenteric 
glands are often slightly enlarged. In addition to the above, there may 
be evidence of some recent infection, which lias been the cause of death ; 
there may be acute bronchitis, broncho-pneumonia, or intestinal catarrh. 

The above lesions represent what has been found in the great major- 
ity of the cases, and very disappointing they are to one who sees them 
for the first time. Xor does the microscopical examination of the organs 
throw any light upon these cases. I have personally examined with care 
the stomach and intestines of more than a dozen cases, several of them 
in which autopsies were made only two or three hours after death, with- 
out finding anything of pathological importance. The theory advanced, 
that atrophy of the intestinal tubules is the explanation of marasmus, 
has found little support. 

The condition of marasmus seems rather to be a failure of assimila- 
tion, owing to imperfect digestion, improper food, unhygienic surround- 
ings, or feeble constitution. As a result, there is a progressive loss in 
weight, feeble circulation, imperfect lung expansion, imperfect oxida- 
tion of the blood, lowered body temperature, and, finally, a deterioration 
of the blood itself. Each of these effects becomes in turn a cause ag- 
gravating all the others, continuing until a condition is reached which 



230 NUTRITION. 

is incompatible with life, for resistance becomes so feeble that the slight- 
est functional disturbance proves fatal. 

Symptoms. — The general history of these cases is strikingly uniform. 
The following is the story most frequently told at the hospital : " At 
birth the baby was plump and well nourished, and continued to thrive 
for a month or six weeks while the mother was nursing it; at the end 
of that period, circumstances made weaning necessary. From that time 




Fig. 32. — Marasmus; a Patient in the Babies' Hospital, Ten Months Old, Weight 
Six Pounds. Weight at birth reported to have been nine pounds. 

the child ceased to thrive. It began to lose weight and strength, at first 
slowly, then rapidly, in spite of the fact that every known form of infant- 
food was tried." As a last resort the child, wasted to a skeleton, is 
brought to the hospital. 

The most constant symptom is a steady loss in weight until a con- 
dition of extreme wasting is reached, at which point they may remain 
for many weeks. The general appearance of these patients is character- 



MARASMUS. 231 

istic. They have an old look ; the skin is wrinkled, has lost its tone, and 
hangs in folds npon the extremities (Fig. 32). The legs are like drum- 
sticks; the abdomen is prominent; the temples are hollow; the fontanel 
is sunken; the eyes large; the features sharp; and the hands resemble 
bird-claws. Often the children are reduced literally to skin and bones. 
Anaemia is a very marked and almost a constant symptom, the amount 
of haemoglobin being frequently reduced to thirty per cent, and in one 
of my cases to eighteen per cent. Anaemic heart-murmurs are frequently 
heard. The body temperature is usually subnormal, unless artificial heat 
is used. A rectal temperature of 95° or 96° F. is very common, and one 
of 93° or 94° F. is occasionally seen. In addition to the pallor of the 
face, there may be a leaden hue due to congenital or acquired atelec- 
tasis. A frequent symptom is general oedema. The first thing which 
calls attention to this is often an unexpected gain in weight. The 
oedema may increase until the cellular tissue of the whole body is affected. 
I have never, however, seen effusions into the large cavities. (Edema is 
usually associated with marked anaemia, and is generally a bad symptom. 
The stools are sometimes normal, but usually contain undigested food, 
and are large in proportion to the amount of food taken. No matter 
how carefully fed, these patients are easily upset. Now and then mucus 
is seen in the stools, but this is neither a constant nor a marked feature. 
Vomiting is excited from the slightest cause, and often food is re- 
gurgitated almost as soon as swallowed. The appetite, in a severe case, 
is almost entirely lost; children refuse to take food from the bottle or 
spoon, and unless fed by gavage they die of inanition. In the earlier 
cases there may be an unnatural hunger, so that the children cry much 
of the time, and are relieved only when the bottle is given. 

The complications are thrush, erythema of the buttocks, and bedsores, 
sometimes over the sacrum and heels, but most frequently upon the 
occiput. Occasionally there is seen a reflex spasm of the muscles of the 
neck, producing a marked opisthotonus, which may last for several days 
or weeks. 

The course of the disease in most cases is steadily downward. It 
may be cut short at any time by acute disease. Frequently these infants 
die suddenly when apparently they arc as well as they have been for 
several weeks. In many instances the autopsy reveals no explanation of 
the sudden death; but in other cases it may be due to the regurgitation 
of food, and its aspiration into the lar} r nx, the patient being too weak to 
cough. Rarely, death occurs from convulsions. In summer, these chil- 
dren wilt with the first days of very hot weather, and die often in a few 
hours from a slight functional derangement of the stomach and bowels. 

Diagnosis. — No sharp line can be drawn between marasmus and mal- 
nutrition. In the wasting which follows chronic disease of the stomach 
and intestines there is usually a history of an antecedent acute attack. 



232 NUTRITION. 

Not infrequently tuberculosis is found at autopsy, even .in infants of a 
few months, in whom there have been no symptoms except those of ma- 
rasmus; but during life tuberculosis may now be recognised in most 
cases by the von Pirquet skin test. 

Prognosis. — This depends on the age of the infant and the extent 
and duration of the disease. If the child is over eight months old, the 
chances of recovery are much better than in one under four months, for 
the fact that it has lived so long is generally evidence of pretty strong 
vitality. Very young infants are always difficult subjects to deal with. 
They go down more rapidly, and build up more slowly than those who 
are older. In most other circumstances the prognosis is much worse 
in cases of long duration. In a given case much depends upon whether 
everything possible can be done for the child : whether a wet-nurse can 
be secured or artificial feeding done in the best manner, and whether the 
patient can have the benefit of the best surroundings, in the country in 
summer and in winter a warm climate where it can be kept out of doors 
the greater part of the time. In institutions cases under four months old 
are usually hopeless. Of those over eight months quite a proportion can 
be saved by proper treatment, even though the body-weight is reduced to 
eight or nine pounds. When recovery occurs it may be complete, and 
the child at two or three years may be as vigorous as any child of its 
age. All these statements refer only to cases of simple marasmus. The 
presence of organic disease puts the case into another category. 

Treatment. — The most important is that which relates to prophy- 
laxis. Maternal nursing should be encouraged by every possible means 
especially among the poor. For those who must be artificially fed the 
important things are a pure milk supply together with proper instruc- 
tion as to how it is to be used in infant feeding. At the same time op- 
portunities for fresh air should be secured. This is a large part of the 
difficulty in institutions. At least one thousand cubic feet per patient 
should be secured with proper ventilation and, what is almost as essential, 
adequate nursing. 

As far as possible, wet-nurses should be obtained if the infants are 
under four months old. For these very young patients success by arti- 
ficial feeding is generally impossible. With those of six months or over, 
good artificial feeding is very frequently successful. In modifying cow's 
milk for these cases the formulas most likely to agree are those with low 
fat, low protein — partially peptonised in many cases — and relatively 
high sugar. Further suggestions will be found in the chapter on Feed- 
ing in Difficult Cases. In institutions we seldom succeed without wet- 
nurses. 

For very young infants, with a temperature which is habitually sub- 
normal, some means of maintaining the body heat must be employed. 
The simplest and usually an effective means is to oil the body and en- 



SCORBUTUS 233 

velop it completely in a cotton jacket and then surround it with hot- 
water bags or bottles. The general management should be much the 
same as described in the chapter on Malnutrition. They require no 
drugs, but a great deal of careful nursing. 



CHAPTER VI. 

DISEASES DUE TO FAULTY NUTRITION. 

The diseases due to faulty nutrition are numerous. There are two, 
however, which have been so clearly shown to originate in this way that 
they may be put in a class by themselves. These are scorbutus and 
rickets. The prevailing opinion of the medical profession is that both 
of these are essentially " food-diseases." The purpose of considering 
them in connection with the disturbances of nutrition is to emphasise 
this relationship. 

SCORBUTUS (Scurvy). 

Scorbutus is a constitutional disease due to some prolonged error in 
diet. It is characterised by spongy, bleeding gums, swellings and ecchy- 
moses about the joints, especially the knee and ankle, haemorrhages from 
the nose, and occasionally from other mucous membranes, extreme hy- 
peresthesia, and often pseudo-paralysis of the lower extremities. Added 
to these local symptoms there is in advanced eases a general cachexia 
with marked anaemia. While scorbutus and rickets are very frequently 
associated, they can not be considered as different forms of the same 
disease. Cases of scorbutus were, however, described in older writings 
under the title of Acute Rickets. 

Scurvy was well recognised and graphically described by Glisson as 
long ago as the middle of the seventeenth century. For our modern 
knowledge of the pathology of this disease we are indebted to the obser- 
vations of Barlow and Cheadle. On the continent of Europe scurvy is 
most frequently known as Barlow's disease. 

For the statistical matter here presented I am indebted to the report 
of the American Pediatric Society's Collective Investigation of Infantile 
Scurvy in 1898, embracing 379 cases, reported by 138 observers. Of 
these, 31 cases were from m} r own practice. 

Etiology. — Age is an important factor; more than four-fifths of the 
cases occur between the sixth and the fifteenth months, and half of 
them between the seventh and the tenth months. Scurvy has been seen 
in infants under a month old. The great majority of the cases reported 
have been observed in private practice, often in the best surroundings. 
Previous disease is not a factor of much importance. Most of the chil- 



234 NUTRITION. 

dren attacked have been in good health up to the development of scurvy. 
In about one-fourth of the number some previous derangement of the 
digestive tract has existed. 

The only etiological factor yet known to bear any constant relation 
to the production of scurvy is diet. The important facts regarding the 
previous diet brought out by the Society's investigation are as follows : 

Breast-milk in 12 cases; alone in 10. 



Previous food ■* 



Raw cow's milk " 5 

Pasteurised milk " 20 

Condensed milk " 60 

Sterilised milk "107 

c Proprietary infant-foods " 214 



4. 
16. 
32. 

68. 



This table shows that while scurvy may occasionally develop with 
almost any variety of food, three stand out prominently — viz., pro- 
prietary infant-foods, condensed milk, and sterilised milk. In all of 
these it would appear that something needed for normal healthy nutri- 
tion is wanting. Scurvy is not likely to follow unless an improper diet 
is continued for a long period, usually several months. In some in- 
stances where it developed in nursing infants, the nurse's milk has been 
examined and found totally inadequate to the needs of nutrition, many 
of the children having exhibited serious disturbances of nutrition before 
any signs of scurvy appeared. 

In several of the cases reported as occurring with a diet of raw or 
pasteurised milk it seems certain that the milk formula used was at fault, 
the most common error in those I have seen being low protein. Several 
cases have come under my personal observation where children had been 
kept for four or five months upon percentages which should have been 
continued only a few weeks. However, I have seen at least three cases 
of scurvy which developed while taking pasteurised milk where the per- 
centages employed could hardly have been the explanation, and the 
heating (167° F. for thirty minutes) seemed to be the cause. However, 
I believe scurvy to be an exceedingly rare result of the pasteurisation of 
milk, so rare, indeed, as not to be weighed against its immense advan- 
tages. With the lower temperature now generally employed (155° F.) 
it need not be feared. The number of cases occurring while upon a 
diet of sterilised milk (usually heated to 212° F. for one hour) is so 
large that we are driven to the conclusion that the heating alone was the 
cause, especially since prompt recovery has frequently followed when 
no other change was made than to discontinue the heating. These facts 
show that sterilised milk should not be continued as the sole diet for 
long periods — i. e., for several months — and that its possible danger 
should b§ kept in mind. 

Xo one fact in the etiology of scurvy is better established than its 
development after the prolonged use of condensed milk or the propri- 



SCORBUTUS. 235 

etary infant-foods. Scurvy occurs not only when the foods are used 
with condensed or with sterilised milk, but also, though less frequently, 
with fresh milk. The inference is that these preparations cause scurvy 
not only by what they lack, but possibly by something which they contain. 
Some have ascribed the results to the ferments present. This view has 
some support in the occurrence of scurvy after the prolonged use of pep- 
tonised milk, an infrequent but a well-established fact. In this respect, 
as with reference to sterilised milk, my personal experience, including 
now nearly one hundred cases of scurvy, coincides with the findings of 
the Society's report. 

While it may be regarded as established that the cause of scurvy is 
dietetic, no single dietetic error can be held responsible for the disease. 
None of the theories yet advanced in explanation of how diet causes 
scurvy is wholly satisfactory. 

Lesions. — The most marked effects of scurvy are seen in the bones, 
blood-vessels, and the blood. The number of recorded autopsies is not 
large, only six being included in the Society's report. I have myself 
had the opportunity of making examinations in three cases. The find- 
ings are remarkably uniform, but represent, of course, the extreme re- 
sults of the disease. The most striking lesion is subperiosteal haemor- 
rhage^ which is practically constant and may occur almost anywhere 
in the body, but affects chiefly the bones of the lower extremities; it is 
often very extensive, and may reach from the knee to the great trochanter, 
or from the ankle nearly to the knee. Extravasations may also be 
found between the muscles, and blood may infiltrate the cellular tissue 
in the neighbourhood of the joints. Besides these lesions resulting 
from haemorrhagic periostitis the bone itself may be affected. Separa- 
tion of the epiphysis from the shaft of some of the long bones, gen- 
erally at the lower end of the femur or lower end of the tibia, is found 
in most of the fatal cases. Notwithstanding the serious lesions near 
the large joints, the joints themselves are usually normal. 

The minute bone changes are somewhat similar to those of rickets. 
But there are also differences of importance. The disposition to haemor- 
rhage, which is altogether the most characteristic feature of scurvy, is 
entirely wanting in rickets. The visceral lesions are inconstant. Those 
most frequently found are small haemorrhages beneath the pleura, 
pericardium, and peritonaeum, sometimes into the various organs, 
also broncho-pneumonia, and nephritis. There may be small ex- 
travasations found upon the surface of any of the mucous membranes. 
The alterations in the blood-vessels are undoubtedly an important 
factor in bringing about the disposition to haemorrhage, but as yet 
they have been very imperfectly studied. The changes in the blood, 
in the gums, and the lesions of the skin will be considered with the 
symptoms. 



236 NUTRITION. 

Symptoms. — In many cases a period of indisposition, fretfulness, 
pallor, and failing nutrition precedes the local symptoms, but usually 
tenderness of the legs is the first symptom noticed. In the beginning 
this is occasional and so slight as to cause the infant to cry only upon 
being handled. Later it becomes almost constant and is very acute. At 
first this soreness is not very definitely localised, but is generally more 
marked about the knees and ankles. Some swelling may be noticed, 
often just above the ankle-joints. Coincident with these may be seen 
the changes in the mouth. The gums are of a deep purplish colour, 
swollen, particularly about the upper central incisors, and may quite 
cover the teeth. They bleed from the slightest irritation, and sometimes 
spontaneously. The child now becomes fretful and cross, sleeps badly, 
loses colour, weight, and appetite. He may become quite cachectic in 
appearance. All these symptoms come on very gradually, often with 
periods of^ a few days in which apparent improvement is seen. Some- 
times they may continue for several weeks without making any percep- 
tible impression upon the child's previously good condition. 




Fig. 33. — ScuitvY Showing Characteristic Swellings and Posture. Patient 8i months 
old, fed exclusively upon malted milk after the age of 3 months. Epiphyseal separa- 
tion at the upper extremity of both humeri, lower extremity of both femora and lower 
extremity of left tibia. Prompt and complete recovery. 

If the disease is recognised, and proper treatment instituted, rapid 
improvement follows, with complete and permanent recovery. If not 
recognised, and the faulty diet is continued, the disease advances to the 
more severe form. The tenderness of the legs becomes exquisite, so that 
any movement or even the slightest touch causes the child to scream 
with pain or apprehension. The posture is very characteristic. There 
is semiflexion of thighs and legs and outward rotation at the hip. (See 
Fig. 33.) In this position the child often lies motionless and voluntary 
movements of the extremities can not be excited. Paralysis is often sus- 
pected. The disability is chiefly owing to the extreme pain which mo- 
tion provokes, but may depend upon epiphyseal separation. Small 
ecchymoses are frequently seen about any of the large joints, resembling 



SCORBUTUS. 237 

the ordinary " black-and-blue " spots, and these often confirm the opin- 
ion previously formed that the child has met with some accident. The 
swelling near the joints, particularly the knee, may be so great that the 
limb is nearly twice the size of its fellow. The mouth symptoms are 
usually striking. In addition to spongy, swollen, bleeding gums, dark 
purplish bags may be seen over teeth not yet through. There may be 
bleeding from the roof of the mouth or from the pharynx. The pain is 
sometimes so severe as seriously to interfere with taking food; there is 
moderate though rarely extreme salivation. Blood may be vomited or 
passed with the fasces or the urine. In the severe cases the stools are 
rarely normal, more or less catarrhal colitis usually being present. The 
general condition is one of grave anaemia, accompanied by a marked 
cachexia and progressive wasting. The child cries almost constantly, 
sleeps little, and is truly a pitiable object. Slight fever is often present. 
Unless recognised and the cause removed, the condition grows steadily 
worse, the symptoms continuing until death occurs either by a slow 
asthenia, or suddenly from heart failure, or from some intercurrent 
disease, such as broncho-pneumonia or acute gastroenteritis. The dura- 
tion of the illness in the fatal cases is from two to four months. 

The onset is gradual in the great majority of the cases, the earliest 
symptoms noticed in the order of frequency being pain and tenderness 
of the legs, soreness and sponginess of the gums, disability, anaemia, 
cutaneous haemorrhages, and very rarely haematuria. 

Pain and tenderness are very prominent, being noted in 95 per cent 
of the Society's cases; in the majority they were present only on motion 
or handling. The location of the pain and tenderness in 184 cases was 
as follows: Lower extremities alone, 133; upper extremities alone, 2; 
lower and upper, 42; lower and trunk, 7. In all but two cases, there- 
fore, the lower extremities were affected, the lower part of the thigh 
and the leg just above the ankle being the usual seat. 

Disability, or pseudo-paralysis, is a very common symptom, and in 
all severe cases a constant one. It exists in varying degrees from a 
slight disinclination to use the limb to complete helplessness. In many 
cases it is more marked than the pain, and has led to a diagnosis of 
poliomyelitis. 

Swellings are associated with pain and tenderness in most of the 
severe cases. They are most marked near the joints, but may extend 
for some distance along the shafts of the bones. In nearly all cases the 
location is the lower part of the thigh or the lower part of the leg, and 
usually of both sides. Swellings are occasionally seen near the wrists, 
elbows, shoulders, and hip-joints ; in rare cases, over the ribs, scapula, 
or ilium. Redness is not generally present, but the parts may have a 
dark purplish colour. It is to the haemorrhages that both the swellings 
and the discoloration are chiefly due. 



238 NUTRITION. 

Protrusion of the eyeball is present in about ten per cent of the 
cases; an extreme exophthalmus is sometimes seen, and is due to orbital 
haemorrhage. 

The gums are affected in nearly all cases, the exceptions being those 
recognised and treated early. Haemorrhage occurs in about one-half the 
cases, and frequently there is ulceration not unlike that of a mercurial 
stomatitis. It is rather curious that, though the lower teeth are cut first, 
the upper gum is almost always most affected, and in the milder cases 
usually alone involved. Of 45 cases in which no teeth had been cut, the 
gums were affected in 24 and normal in 21. This is sufficient to dis- 
prove the old opinion that the gums are affected only when teeth have 
appeared. The severe inflammation and ulceration sometimes seen 
seem to be the result of secondary infection. 

Haemorrhages beneath the skin are present in about half the cases. 
They are rarely extensive, usually multiple, and their location is no 
doubt often determined by a slight traumatism. Haemorrhages from 
the mucous membranes are not quite so frequent. There may be bleed- 
ing from the gums, nose, bowels, kidneys, and rarely from the stom- 
ach. Haemorrhages in most cases are frequently repeated, but seldom 
profuse. 

Epiphyseal separation is seen only in very severe cases. It is most 
frequently either of the lower epiphysis of the femur or the tibia, or the 
upper epiphysis of the humerus, and is often bilateral. The actual sepa- 
ration may be caused by some slight injury, the condition of the bone 
predisposing to this occurrence. In three cases of my own with sepa- 
ration which recovered, rapid union occurred under anti-scorbutic 
treatment. 

Anaemia is slight in the early stage, but increases as the disease 
progresses. Blood examinations may show great reduction of the haemo- 
globin, sometimes to thirty-five or forty per cent; also in nearly all 
cases a proportionate reduction of the red cells. The changes are those 
of an ordinary secondary anaemia. 

The urine contains albumin in one-fourth of the cases ; in nearly half 
of those containing albumin casts also are found. In rare cases haema- 
turia has been an early symptom. Blood cells usually in moderate 
numbers are found in practically all but the mildest cases, and are of 
some diagnostic importance. 

Evidences of general malnutrition are present in all advanced cases, 
varying, of course, greatly in degree. In a few infants under my own 
observation the weight, colour, and general appearance of health have 
continued in spite of very decided local symptoms. In most of them 
the impaired nutrition is shown by loss of appetite, occasional attacks of 
vomiting, and still more frequently by derangements of the bowels, 
which vary from slight indigestion to a serious catarrhal condition of 



SCORBUTUS. 239 

both small and large intestine. It is with the latter that the discharge 
of blood is usually seen. 

Association with Rickets. — In the Society's investigation great pains 
were taken to obtain definite and accurate data regarding this. Of 
the cases, 340 in number, in which this point was noted, symptoms of 
rickets were present in 152, or 45 per cent; these symptoms were re- 
corded as slight in 72; marked in 64; and not specified in 16. In the 
remainder of the cases, 55 per cent, it is definitely stated that symptoms 
of rickets were absent. It is also stated that in 50 of the patients which 
were rachitic, the rickets antedated the development of the scurvy. 
From these facts it would seem to be pretty well established that 
though rickets and scurvy have points of resemblance, such as the age 
when they are seen, bony changes, dependence on defective nutrition, 
etc., they can not be regarded as different forms of the same disease. 
The two most striking characteristics of scurvy — viz., tendency to haem- 
orrhages and prompt curability by fresh food and fruit juices — have no 
counterpart in rickets. However, their co-existence in the same patient 
is of common occurrence. 

Diagnosis. — The disease with which infantile scurvy is most fre- 
quently confounded is rheumatism. In fully four-fifths of the cases 
which have come to my own notice this has been the previous diagnosis. 
The extreme rarity of rheumatism under one year should always make 
one cautious; pain and tenderness of the legs only, should, in an infant, 
invariably suggest scurvy rather than rheumatism. The extreme disa- 
bility has often led to a diagnosis of poliomyelitis, but here again the 
acute tenderness should set one right. Many cases of scurvy come into 
the hands of the orthopaedic surgeon with a diagnosis of joint or spinal 
disease. Where the swelling was mainly of one limb I have twice known 
a diagnosis of malignant disease to be made, from the cachexia, the 
shape of the swelling, the discoloration, and the pain. I have known 
two cases to be operated upon by eminent surgeons, once with a diag- 
nosis of sarcoma and once of ostitis of both tibiae. Not until the sub- 
periosteal haemorrhages and epiphyseal separation were discovered was 
the nature of the trouble suspected. 

The diagnosis of scurvy seldom presents any difficulties to one who 
has once seen a case. No one need err if the essential features of the dis- 
ease are kept in mind: the extreme soreness of the legs, spongy, swollen 
gums, swelling near the large joints, a tendency to haemorrhages, and 
usually a history of the prolonged use of some proprietary infant food, 
or sterilised or condensed milk. The epiphysitis of hereditary syphilis 
has many symptoms in common with scurvy, but it usually occurs at an 
earlier age (before the fifth month) and other evidences of syphilis are 
usually present. If any doubt exists, this will be removed by the prompt 
improvement and generally rapid cure following an anti-scorbutic diet. 



240 NUTRITION. 

Prognosis. — This is invariably good if the disease is recognised early. 
No patients with symptoms so serious improve with such marvellous 
rapidity as -do the great majority of those with scurvy, under proper 
management. The figures of the Society's report on this point are 
interesting. The average duration of the disease before treatment was 
begun in over three hundred cases was somewhat over three weeks. In 
eighty per cent striking improvement was noticed during the first week 
of treatment, and in forty per cent within three days. Over two-thirds 
of these cases were well within three weeks, and nearly one-third within 
one week, after the beginning of treatment. 

It is only when the disease is of long standing, when the malnutri- 
tion ' is severe, or when serious complications, usually involving the 
digestive tract, are present that the symptoms persist and the issue 
becomes doubtful. It is difficult to tell what the exact mortality of 
scurvy is. Any case allowed to go on may result fatally. The younger 
the infant the more likely is this to occur. I have seen four deaths 
in nearly one hundred cases. In one of my patients death resulted from 
haemorrhage which followed an incision into an epiphyseal swelling at 
the lower end of the femur, made before I saw the patient, and which 
persisted despite all treatment. Barlow's early article included thirty- 
one cases with seven deaths. It is rare that scurvy leaves any permanent 
effects. Recovery is not only rapid but complete. Relapses are ex- 
tremely rare and have been observed only in one or two cases, where 
chronic indigestion existed of so extreme a character that proper feeding 
was impossible. ' The after-effects are usually the result of prolonged mal- 
nutrition, of which the attack of scurvy was only one manifestation. 

Treatment. — This is remarkably simple — viz., to discontinue all pro- 
prietary foods, condensed milk or sterilised milk, and to substitute a 
diet of fresh cow's milk, modified to suit the child's digestion. With 
this treatment alone improvement will soon begin and gradually com- 
plete recovery takes place. However, when fresh fruit juice is added 
improvement is much more rapid. It should always be combined with 
the change in diet. Orange juice is to be preferred, but the juice of 
any fresh ripe fruit will answer the purpose. Oranges should be sweet 
and fresh. From two to four ounces a day are required, best in 
divided doses, given about one hour before the milk-feeding. It may 
be given plain, or diluted with water. In some cases, when not well 
tolerated by the stomach, it is better given at night, when no food is 
taken. Potato also has marked anti-scorbutic properties, and may be 
given in the form of a puree to infants as young as eight or ten months. 
The only really difficult cases to manage are those in which the general 
condition approaches one of marasmus, or when scurvy is accompanied 
by marked gastric or intestinal disturbance. When an intestinal catarrh 
is present, with the bowels moving five or six times a day, one may hesi- 



RICKETS. 241 

tate to give the fruit juice for fear of increasing these symptoms. In 
a number of instances I have seen intestinal symptoms, which had re- 
sisted ordinary measures, immediately improved by the fruit juice, thus 
establishing their intimate connection with the scorbutic condition. 

Other things of value are fresh beef juice, and for older children 
all fresh vegetables, especially potato. The anaemia and malnutrition 
call for iron, cod-liver oil, and other tonics, which should be given after 
active symptoms of the disease have disappeared. Infants with scurvy 
should be handled as little as possible, and should be particularly pro- 
tected againt exposure in their extremely susceptible condition. The 
affected limbs should be immobilised by splints during the period of 
marked symptoms, always if epiphyseal separation has taken place, and 
in many other severe cases. 

RICKETS (Rachitis). 

Rickets is a chronic disease of nutrition. While the only important 
anatomical changes are found in the bones, it is not to be regarded as a 
bone disease; but as a very complex pathological process, the result of 
disturbed metabolism, which affects chiefly the bones, but also muscles, 
ligaments, mucous membranes, and nearly all the organs of the body, 
particularly the nervous system. It occurs especially between the ages 
of six and eighteen months. It is not very common in the country, but 
is exceedingly frequent in most large cities. While not a fatal disease 
per se, rickets adds very greatly to the danger from all acute diseases 
in infancy, and even to some degree also to those of later life. Under 
proper conditions of diet and hygiene it tends to spontaneous recovery. 

Etiology. — Certain facts in the causation of rickets are well known. 
It is closely related to improper feeding and bad hygienic surroundings. 
It is not common in nursing children unless lactation is unduly pro- 
longed, 1 as, for example, where nursing is continued for fifteen to 
eighteen months without other food. Artificially fed children are much 
more prone to the disease, especially those who are badly fed. The diet 
in these cases is most frequently deficient in fat, and often at the same 
time in protein, while it is apt to contain an excess of carbohydrates. 
It is somewhat difficult to separate the effects which these different fac- 
tors produce. It appears, however, that the most important factor is 
the deficiency in fat. Rickets is exceedingly common in children reared 
upon the proprietary foods, nearly all of which are very low in fat 
and contain an excess of carbohydrates. It is also common in chil- 
dren who are reared upon sweetened condensed milk, and for precisely 

1 An exception to this statement must be made in the case of Italian and Negro 
children. In this class as observed in New York it is not uncommon to see marked 
rickets in those getting nothing but the breast. 
17 



242 NUTRITION. 

the same reason. When both fat and protein are low, rickets is more 
likely to result than when only the fat is deficient. 

Certain experiments have been made which show that a condition of 
the bones resembling rickets may be produced in animals by a diet de- 
ficient in calcium salts, and furthermore that this may be cured simply 
by the addition of these salts to the food. The conclusion can not, how- 
ever, be drawn that rickets in children is produced in this manner. In 
the first place the bony condition in the artificial disease is not histolog- 
ically the same as that seen in rickets; again, rickets in the child is not 
cured simply by the administration of calcium salts ; and, finally, rickets 
develops where these elements have not been deficient in the food. 

Hygienic surroundings are next in importance to diet. Although, as 
previously stated, rickets is essentially a disease of cities, being most 
often seen in children living in crowded tenements where the effects of 
improper food are most strikingly shown, yet even here the disease is rare 
in those avIio get a plentiful supply of good breast-milk. 

Distribution of Rickets. — According to Palm, the disease is almost 
unknown in the extreme north — Greenland, Iceland, Norway, and Den- 
mark. It is also very rare in China, Japan, Greece, Turkey, and the 
southern portions of Italy and Spain. Its greatest frequency is in the 
temperate zone. The general immunity of children in southern latitudes 
appears to be due to the out-of-door life, and the almost universal custom 
of maternal nursing. In the cities of America no race is exempt from 
the disease. In New York the greatest susceptibility is among the 
Negroes and the Italians. The extreme cases of rickets seen are almost 
invariably in one of these nationalities. It is exceptional to see in a 
dispensary or hospital a child of either of these races who does not show, 
to a greater or less degree, the signs of rickets. These two southern races 
seem to bear very badly the climate and the confined life of the northern 
cities. So far as my observations are concerned, there is no peculiarity 
in the food of these people which explains the prevalence of rickets 
among them, and this must be attributed to a race peculiarity. In the 
country, the immunity from rickets is due partly to the more prevalent 
custom of maternal nursing, and partly to the better surroundings; the 
increased resistance of the children rendering them much less suscep- 
tible to the influences of bad feeding than is seen in the cities. In New 
York among dispensary and hospital patients, rickets is exceedingly com- 
mon, and is seen chiefly in the foreign elements of the population. 

Heredity. — There is no evidence that rickets is hereditary. Any 
cachexia in the parents, such as syphilis, tuberculosis, or alcoholism, 
may, however, by diminishing the child's resistance, be a predisposing 
cause of rickets. The later children in a family are more likely to be 
affected than the earlier ones, especially when the interval between the 
pregnancies has been short. 



RICKETS. 243 

Previous Disease. — Eickets not infrequently develops in syphilitic 
children; the connection, however, seems to be no closer than with any 
other cachexia. Chronic disorders of the digestive tract sometimes pre- 
cede and often follow the development of rickets. There is no sufficient 
ground for believing that rickets exerts any protective influence against 
tuberculosis; on the contrar} r , the thoracic deformity of rickets may be 
a predisposing cause. 

Eickets affects both sexes with equal frequency. The symptoms usu- 
ally manifest themselves between the sixth and eighteenth months. 
Congenital and late rickets will be considered separately. 

Nature of the Disease. — Eickets is a disorder of nutrition, the result 
of some disturbance of metabolism in which calcium plays a very impor- 
tan role. The exact nature of this disturbance is not yet understood. 
Three theories have been advanced in explanation of the deficiency of 
calcium in the bones which is the only constant lesion of the disease. 
The first one, that rickets is due to a lack of calcium in the food, is not 
supported either by clinical or experimental evidence. The second theory 
is that the disease is due to an increased excretion of calcium as a result 
of disturbances of digestion. The frequent occurrence of rickets after 
prolonged disturbances of digestion lends some support to this view. 
The third theory advanced is that although sufficient salts are furnished 
in the food, they are excreted in excess because the bones are incapable 
of assimilating them. 

Lesions. — The only constant and characteristic lesions of rickets are 
found in the bones; these changes are sufficiently definite to give it a 
place as an essential disease and not merely a form of malnutrition. It 
is still a matter of dispute whether these bony changes are to be consid- 
ered as inflammatory, or simply as the result of disordered nutrition. 
Disordered nutrition and chronic inflammation are closely allied, and it 
really makes but little difference which view is taken. Occurring at a 
time when the growth of bone is so rapid, the effects of rickets are very 
striking and very serious. 

In order to appreciate how the bones are affected by rickets, it must 
be remembered that the long bones grow in length by the production of 
bone in the cartilage between the epiphysis and the shaft ; that the shaft 
grows in thickness by the production of bone beneath the inner layer of 
the periosteum ; and that the medullary canal is continually increasing in 
size by the absorption of the inner layers of the bone. In rickets there is 
an exaggerated production of cartilage at the epiphysis, and excessive 
cell-growth beneath the periosteum, while the process of ossification in 
these tissues goes forward slowly and imperfectly, or is entirely arrested. 
At the same time the absorption of the medullary layers may be even 
more rapid than normal. In health the growth of bone in length is much 
.more rapid than its increase in diameter, owing to the greater activity 



244 NUTRITION. 

of the changes taking place at the epiphysis; so, in rickets, it is at the 
extremities of the long bones that the most marked changes are seen. 

One of the most striking features of rachitic bones is their unnatural 
flexibility. This is due to deficient ossification in the superficial layers of 
the shaft of the long bones, and also at their extremities. Normally, 
bone contains about one-third organic and two-thirds inorganic matter. 
In marked rickets the proportions are reversed, the bones often contain- 
ing twice as much organic as inorganic matter. Changes are seen in all 
the long bones, but all are not affected to the same degree. Sometimes 
those most affected will be the bones of the leg, sometimes those of the 
forearm, and sometimes the ribs. The extent varies with the severity 
of the process. 

There are characteristic changes in form. The most constant is en- 
largement of the epiphyses of all the long bones. This is most strikingly 
seen in the lower extremities of the radius and tibia. The enlargement 
may be so marked that the width of the epiphysis is increased by one- 
half. All the sharp angles, borders, and prominences of the bones are 
rounded off. The curvatures of rachitic bones are more fully described 
under the head of Symptoms. They may be due to a variety of causes. 
Some are simply an exaggeration of the normal curves, much increased 
by the sAvelling of the epiphyses; others are due to muscular action, to 
atmospheric pressure, to some unnatural posture, such as the cross-legged 
position, to the weight of the limbs, or to the weight of the body. The 
principal change in the form of the flat bones consists in the production 
of large bosses or prominences due to thickening of the bone, usually 
about the centre of ossification. These bosses are soft and spongy. Frac- 
tures are not uncommon. The bones most frequently broken are the 
radius and ulna ; next, the clavicle, the ribs, the humerus, and the femur. 
The fractures are usually of the green-stick variety. There is a bending 
of the outer and a fracture of the inner layers of the shaft of a long 
bone. This results in more or less impaction, and is usually followed 
by the production of considerable callus. The epiphyseal changes result 
in arrested growth in length, rachitic bones being usually much shorter 
than normal. Increased vascularity is seen in the bosses upon the flat 
bones, at the extremities of the long bones and upon stripping the peri- 
osteum from the shaft. 

In a longitudinal section of one of the long bones, the principal 
change seen at the extremity is that the cartilaginous layer which unites 
the epiphysis and the shaft is very much enlarged, both in width and 
thickness, the latter being sometimes four or five times the normal. 
This cartilaginous area is of a bluish colour, rather softer than normal 
cartilage. On one side it blends with the cartilage of the epiphysis, on 
the other it presents an irregular dentated border, and in it the calcified 
areas are irregular and scattered. The epiphyseal centres of ossification 



RICKETS. 245 

are enlarged, softer, and more vascular than normal, thus increasing the 
size of the extremity of the bone. In the shaft, the outer layers of bone 
are thickened and soft, like decalcified bone, the deeper parts being 
firmer, while the deepest layers may be completely ossified. The medul- 
lary canal is much more vascular than normal, its contents resembling 
granulation tissue. Toward the extremities the trabecular spaces are 
much increased in size, so that the bone appears unnaturally porous. 
On vertical section of one of the flat bones — e. g., one of the bosses upon 
the skull — there is found a great increase in the size of the trabecular 
spaces. The bosses are made up of large spongy masses, so soft as to be 
easily indented with the finger. 

Microscopical Changes. — At the junction of bone and cartilage at the 
extremity of one of the long bones, there are readily traced in normal 
bone (Fig. 34) several distinct zones. Next to the hyaline cartilage (a) 
there is a proliferating zone (fr), made up of cartilage cells and matrix, 
the cells having no orderly arrangement. Next to this is a columnar 
zone (c, d), in which the cartilage cells are arranged in regular rows or 
columns. Adjoining this is the zone of calcification (e) ; and, finally, 
there is the zone of ossification (/, g), where true bone is formed. 

In rickets (Plate IV and Fig. 35), the principal changes are seen in 
the proliferating and columnar zones. The proliferating zone (Fig. 35, 
o) is increased chiefly by the multiplication of new cells; it is also more 
vascular than normal. The columnar zone (c) is affected in a similar 
way and. to a much greater degree. It is less regular in its formation, 
and, instead of containing but few vessels, it shows large vascular chan- 
nels, sometimes surrounded by medullary spaces (e). The ossification 
zone, instead of being narrow and sharply outlined, is broad and very 
irregular. Calcified areas (/) may be seen in the midst of regions which 
are cartilaginous, while masses of cartilage (]i) occupy areas which 
should be completely calcified. In some places there appears to be a 
transformation of cartilage into bone-tissue of an inferior sort by a direct 
or metaplastic process. In the shaft there is seen more or less thicken- 
ing, and an increased vascularity of the periosteum. Beneath the inner 
layer there is excessive cell-proliferation, while calcification of this new 
tissue is imperfect or absent, and instead of hard, compact bone, we find 
irregular, spongy masses. In the spongy bone there is considerable thick- 
ening, with an erosion of bony trabecular, which results in the formation 
of large medullary spaces filled with blood-vessels and connective tissue 
rich in cells. 

Termination of the Rachitic Process. — After a variable time, usually 
from three to fifteen months, the active proliferative process going on in 
the cartilage and beneath the periosteum ceases, and is gradually replaced 
by ossification. The bone becomes less vascular, and a rapid formation 
of bone takes place in the normal way. In addition, there is in some 



246 



NUTRITION. 



places a direct transformation of cartilage into bone. Condensation and 
contraction take place in the spongy masses of bone. As the result of 
this, the affected bone may become even harder than normal; often it is 
ivory-like, Its structure, however, is never quite like that of healthy 
bone. 

In the long bones the epiphyseal swellings slowly diminish, and may 
quite disappear; the slighter curvatures may be entirely overcome, and 




Fig. 34, — Section Through Ossification Zone of Normal Bone (Ziegler). a, hyaline 
cartilage; b, zone of beginning cartilage proliferation; c, columns of cartilage cells; 
d, columns of hypertrophic cartilage; e, zone of temporary calcification; /, zone of 
primary medullary spaces; g, zone of primary bone formation; h, fully developed 
spongy bone; ?, blood-vessels; k, layer of osteoblasts. 



the greater ones much lessened. The beading of the ribs becomes almost 
imperceptible; the bosses upon the skull shrink very markedly, and may 
leave scarcely a trace of their existence. In most cases the active process 
in rickets comes to an end by the time the child is two and a half years 
old, often at two years. 



PLATE IV. 




Bone in Rickets. 

Longitudinal section of a rib at the junction of the costal cartilage, in a severe 
case of rickets (slightly magnified). C = costal cartilage, B = bone, A = proliferating 
cartilage-zone, which is much widened. Between the hypertrophied cartilage cell- 
columns (a) making up this proliferating zone, are seen medullary spaces (b) contain- 
ing blood-vessels. In this zone lie masses of bone (c) not calcified. The calcification 
zone is almost wanting, only scattered islands (d) of calcified cartilage-cells being seen. 

Beyond this proliferating zone (A) is a layer of bony tissue (B) made up of small 
bands of which only a few have a nucleus containing lime (e). These nuclei appear 
black. The bony bands differ both in form and arrangement from those of normal 
ossification. Between the bony masses are medullary spaces which appear light in the 
illustration. At (g) the beginning of cartilage proliferation is seen. Above this zone 
the cartilage is normal. {From Karg and Schmorl.) 



RICKETS. 



247 



Visceral Lesions. — These are not infrequent, but are not essential to 
rickets. In the lungs they are due to deformities of the chest wall and 




Fig. 35. — Rachitic Bone (Ziegler). Longitudinal Section Through Ossification 
Zone of the Upper Diaphysis of the Femur of a Moderately Rachitic 
Child One Year Old (highly magnified), a, unchanged hyaline cartilage; b, be- 
ginning cartilage proliferation; c, columns of proliferated cartilage cells; d, col- 
umns of proliferated hypertrophic cells; e, medullary spaces containing blood-ves- 
sels lying within the cartilage; /, calcified cartilage; g, bony tissue; h, remains of 
cartilage within the bony tissue; i, point of uncalcified bony tissue; k, calcified bony 
tissue. 



to complications. Beneath the deep lateral furrows which are so com- 
mon, there is found a part of the lung in a state of more or less complete 
collapse. This is accompanied by emphysema of the portion just ante- 



248 NUTRITION. 

rior to it. Acute and chronic bronchitis and broncho-pneumonia are 
exceedingly frequent. A low grade of chronic catarrhal inflammation 
of the stomach and intestines is common, and is often associated with 
dilatation of these organs. The spleen is enlarged in most cases during 
the period of active symptoms. This is usually moderate in degree, 
although marked enlargement is not at all rare. The swelling of the 
spleen is chiefly due to simple hyperplasia. Enlargement of the liver 
is less frequent, and may occur with or without that of the spleen. 
There are nq constant changes in the structure of these organs. The 
lymph nodes are frequently enlarged. Eachitic patients are more prone 
to these swellings than are other children. They are due to simple hyper- 
plasia, and have no close connection with rickets. Cerebral changes are 
rare, and those described are rather of accidental occurrence than de- 
pendent upon the rachitic process. As stated under Symptoms, enlarge- 
ment of the head is usually due to thickening of the cranial bones. Al- 
though hydrocephalus is occasionally seen, it is extremely doubtful 
whether it is more frequent than in patients not rachitic. Hypertrophy 
of the brain has been described in connection with rickets, but as yet 
this does not seem to be established by sufficient pathological evidence. 
The muscles are flabby from imperfect nutrition, and sometimes atrophied 
from disuse, but no essential anatomical changes have been demonstrated 
in them. 

Symptoms. — A well-marked case of rickets makes a striking picture 
(Plate V), and one not easily mistaken. There are seen the large head, 
beaded ribs, narrow chest, prominent abdomen, symmetrical swellings of 
the epiphyses of the wrists and ankles, and curvatures of the extremities. 
The beginning of symptoms is nearly always insidious, and the patient 
does not usually come under observation until they have existed for sev- 
eral weeks, often several months. 

Early Symptoms. — The most constant early symptoms are sweating 
of the head, extreme restlessness at night, constipation, beading of the 
ribs, and cranio-tabes. The head-sweating is rarely absent, and may con- 
tinue for several months. It is especially profuse during sleep, the per- 
spiration standing out in large drops upon the forehead, often being 
sufficient to wet the pillow. This is one of the causes of the nasal and 
bronchial catarrhs so common in rachitic infants. There is marked rest- 
lessness during sleep : the children tossing about the crib, kicking off the 
clothes, and never having the quiet, natural slumber of healthy infants. 
This may be due to many causes, but when persistent and associated with 
marked perspiration of the head, rickets should be suspected. In many 
rachitic infants more serious nervous symptoms appear early; there may 
be tetany, laryngismus stridulus, or general convulsions. Constipation is 
frequently seen as an early symptom, although it is more marked in 
the later stages of the disease. 



PLATE V. 




Typical Rickets. 

Showing the large head, narrow chest, prominent abdomen, marked enlargement 
of the epiphyses at the wrists and ankles. There are also curvatures of the forearms 
and legs which are not so well shown. 

The patient a child two and a half years old. 



RICKETS. 249 

The beading of the ribs is almost invariably the first appreciable 
change in the bones, and it is well-nigh constant. This forms the so- 
called " rachitic rosary," consisting of nodules at the line of junction of 
the costal cartilages and the ribs. It may be slight, or there may be a 
row of knobs as large as small marbles. In many cases with marked 
thoracic deformity, little or no beading of the ribs is seen externally, 




Fig. 36. — Rachitic Skull. From coloured child two years old, horizontal section, inner 
surface; showing thickening of the bones, especially the frontal, and open fontanel. 

although at autopsy it is found to be very marked upon the internal sur- 
face of the chest (Plate VI). Beading of the ribs was noted in all but 
two of one hundred and forty-four successive cases of rickets, at the time 
of the first examination. In infants under six months there may be 
found soft spots in the cranium, usually over the occipital or posterior 
portions of the parietal bones. These are from one-fourth to one inch in 
diameter, and there are usually several of them present. By pressure 
with the finger they give a sort of parchment-crackling sensation. This 
condition is known as cranio-tabes. Cranio-tabes is believed to be more 
frequent when syphilis is associated with rickets, and it is seen also in 
syphilitic cases which are not rachitic. A rachitic cachexia is not usually 



250 



NUTRITION. 



present until the symptoms have existed for several months, and in many 
cases it is not seen at all. 

Deformities. — The deformities of 



symmetrical in character, and usually 




Fig. 37. — Rachitic Head. Italian child two 
years old; square, prominent forehead and 
flat vertex. 



rickets are almost invariably 
numerous. In extreme cases 
almost every bone in the body 
is affected. 

Head. — This usually appears 
to be too large, and although it 
may not be greater in circum- 
ference than that of a healthy 
child of the same age, it is out 
of proportion to the rest of the 
body. In marked cases the in- 
crease in circumference may be 
one or two inches. The enlarge- 
ment is chiefly due to thicken- 
ing of the cranial bones. In one 
case with marked deformity, I 
found the skull over the parietal 
bones half an inch in thickness 
(Fig. 36). This thickening di- 
minishes with recovery, but in 
most cases the head remains 
throughout life larger than it 




Fig. 38. — Rachitic Skull from a Child One Year Old. 
Showing frontal and parietal bosses and wide fontanel. 



RICKETS 251 

should be. The shape of the rachitic head is somewhat square (Fig. 37), 
owing to the formation of large bosses over the parietal and frontal emi- 
nences. It is flattened at the occiput from pressure, and flattened also at 
the vertex. In extreme cases, the prominences upon the frontal and 
parietal bones may be so great as to produce quite a marked furrow along 
the line of the sagittal and frontal sutures, and one at right angles to this 
along the coronal suture (Fig. 38). This condition gives unusual promi- 
nence to the forehead. Marked deformity of the head has been observed 
in thirty-three per cent of my cases. The sutures may remain open for an 
unnatural time, occasionally until the end of the first year. The fontanel 
is late in closing, being frequently found open at two and a half, and 
sometimes even at three years. Often at eighteen or twenty months 
the fontanel is two inches in diameter. The veins of the scalp are 
often prominent, and the hair is frequently worn from the occiput, 
owing to restlessness during sleep. Occasionally rickets and hydrocepha- 
lus are associated, but the latter is the least frequent of all causes of the 
enlargement of the head. 

Chest. — Beading of the ribs has already been mentioned. This is the 
most characteristic feature, but in the majority of cases there are, in 





Fig. 39. — A, Horizontal Section of a Rachitic Chest, child two years old, showing 
lateral furrows; B, Section of Chest of Healthy Child of the Same Age. 

addition, lateral depressions over the lower third of the chest, at the line 
of junction of the cartilages with the ribs, with eversion of the lower 
borders of the ribs. In severe cases these depressions or furrows are so 
great as to cause serious deformity (Plate VI). Usually there is a 
great diminution in the transverse, and an increase in the antero-posterior, 
diameter of the chest. Fig. 39 shows the outline of the chest of a rachitic 
child of two years, compared with that of a healthy child of the same 
age. Another frequent deformity is the " rachitic girdle," which con- 
sists in a transverse depression about two inches broad, extending from 
one side of the chest to the other, just above its lower border. A less 



252 



NUTRITION. 



frequent deformity is the " funnel chest/' a deep central depression over 
the ensiform cartilage. This is sometimes nearly an inch and a half in 
depth. Marked thoracic deformity was seen in twenty per cent of my 
cases, and in only a small proportion was the chest normal. 

The factors in the production of the thoracic deformity are the con- 
traction of the diaphragm, atmospheric pressure, and soft chest walls, 
these sinking in at the point where they have least resistance, viz., at the 
junction of the costal cartilages and the ribs. When there exists any 
obstruction to the entrance of air, as with bronchitis, hypertrophied ton- 
sils, or adenoid growths of the pharynx, the thoracic deformities are exag- 
gerated. Irregular chest deformities depend upon the co-existence of 
pathological conditions in the lungs. Pigeon-breast is occasionally seen, 
but it is doubtful if this depends upon rickets alone. 

Spine. — In very many of the milder cases this is normal. The most 
characteristic deformity consists in a posterior curve (kyphosis), (see Fig. 
40), which is a general one, usually extending from the mid-dorsal to 

the sacral region. This existed in forty-six 
per cent of my cases. In the early part of 
the disease it disappears entirely on sus- 
pending the child, or making extension upon 
the extremities; but in cases of long stand- 
ing it may not disappear entirely by these 
tests. Very much less frequently there is 
seen a rotary curvature. This, in my expe- 
rience, has been more frequently with the 
convexity to the left side than to the right — 
the opposite of the common form of lateral 
curvature seen in young girls. Marked lat- 
eral curvature in children under three years 
is usually rachitic. 

The clavicle is affected only in severe 
cases. The usual deformity consists in an 
exaggeration of the anterior curve at the 
inner third of the bone, which is somewhat shortened and its extremities 
enlarged. It is not infrequently the seat of green-stick fracture. 

Deformities of the pelvis belong to obstetrics rather than to paedi- 
atrics. The most common rachitic change is a diminution of the antero- 
posterior diameter and a narrowing of the subpubic arch. 

Extremities. — Deformities of the upper extremities are usually sym- 
metrical. The humerus is affected only in severe cases. It has a forward 
and outward curve, although rarely a very marked one. Both the epiphy- 
ses are enlarged, although the upper one can not well be made out 
unless the child is very thin. The radius and ulna are frequently 
affected. They present a convexity upon their extensor surfaces (Plate 




Fig. 40. — Rachitic Curvature 
or the Spine. 



PLATE VI. 





Deformity of the Chest in Severe Rickets. 

In the upper picture, giving the external view, is shown a deep oblique furrow at 
the junction of the ribs and costal cartilages, these meeting at an acute angle. 

In the lower picture the ribs have been separated from the spine and spread open, 
showing the same deformity as it appears from within, looking forwards. 

From a coloured child ten months old. 



RICKETS. 



253 



V), which in some cases is very marked, particularly in children 
who have been creeping. Green-stick fractures here are quite frequent 





A B 

Fig. 41. — Multiple Fractures in Rickets. 
Showing both arms of the same patient ; fractures also of both femora. 



as they are also in the femora. They are frequently multiple and 
occur from very slight causes, sometimes apparently from muscular 
contraction. Cases with such fractures 
are sometimes classed as osteomalacia. 
Rachitic changes at the epiphyses are 
more common than in the shaft, en- 
largement of the epiphyses at the wrist 
being one of the most constant bony de- 
formities of rickets (Plate V). It was 
present in ninety-five per cent of my 
cases. Less frequently similar swellings 
are seen at the elbow. Enlargement of 
the ends of the metacarpal bones or the 
phalanges I have seen but seldom and 
only in extreme cases. 

The lower extremities are rather 
more frequently affected than the upper, 
but in a similar way. The femur is in- 
volved only in severe cases ; it commonly 
presents a general forward and outward 
curve, which is mainly due to the weight 
of the legs as the child sits. Occasion- 
ally there is also an outward rotation 
of the femur, where children have been 
allowed to sit much in a cross-legged posture. When such children begin 
to walk, the toes are turned very far outward. The principal deformities 




Fig. 42. — Typical Bow-legs of 
Severe Form. 



254 



NUTRITION. 




of the lower extremity are bow-legs (Fig. 42) and knock-knees (Fig. 
43). Knock-knees are more common in females, and are believed to 
be due to an overgrowth of the inner condyles of the femur. Enlarge- 
ment of both condyles can be 
demonstrated in most of the 
marked cases of rickets. The 
cases of slight bow-legs may 
be due simply to swelling of 
the epiphyses, the shaft of 
the bone being quite normal. 
This point I have verified 
by post-mortem observations. 
Such are probably most of 
the deformities which dis- 
appear spontaneously. The 
most severe cases of bow- 
legs are often associated with 
some degree of antero- 
posterior curvature, 
and the latter may be 
the principal deform- 
ity. Enlargement of 
the epiphyses at the 
ankles is usually pres- 
ent when it is seen at 
the wrists, and nearly to the same degree. Enlargement of the upper 
epiphyses of the tibia and the fibula is seen only in severe cases. The 
cause of the deformities of the leg is not, primarily, at least, walking 
too early, since they are common in children who have never walked; 
slight deformities, however, may be aggravated by early walking. A 
change which has not been sufficiently emphasised is the arrested growth 
of the long bones ; this is one of the most characteristic features of rickets. 
A rachitic child of three years often measures in height five or six 
inches less than a healthy child of the same age, the difference being 
almost entirely in the lower extremities. 

All the ligaments, but particularly those about the large joints, are 
lax and frequently elongated. This may lead to the deformity known as 
weak ankles, or to an over-extension at the knee (genu recurvatum) ; 
also to unnatural mobility at the hips, shoulders, elbows, and wrists. 
The condition of the ligaments plays an important part in the produc- 
tion of spinal deformities. 

Muscles. — The muscular symptoms of rickets are almost as constant 
and as characteristic as those of the bones. The muscles are small, very 
flabby, and poorly developed; hence rachitic children are unable to sit 




Fig. 43. — Knock-knees. 



RICKETS. 255 

erect, or to stand or walk at the proper age. Of one hundred and fifty- 
one cases in which the date of walking alone was investigated, only 
twenty-seven, or eighteen per cent, walked before the fifteenth month; 
forty-seven per cent were not walking at the eighteenth month; twenty 
per cent, not at two years ; and ten per cent, not at two and a half years. 
Late walking is one of the most common symptoms for which advice 
is sought by parents with rachitic children. The muscular power in the 
extremities is sometimes so feeble as to suggest paralysis. I have seen 
a number of cases in which the symptoms so resembled paralysis, that 
even expert diagnosticians were unable to differentiate rickets from pol- 
iomyelitis except by the electrical reactions, those in rickets being usually 
normal or exaggerated. In other cases the symptoms may suggest 
cerebral palsy of the flaccid type. The muscular symptoms may be marked 
when the bony changes are slight, and conversely. As no lesions of the 
muscles have been demonstrated, the symptoms are probably due to 
imperfect nutrition. Two other symptoms depend chiefly upon the 
condition of the muscles, viz., pot-belly and constipation. 

Pot-belly is quite an early symptom, and in most cases a very marked 
one (Plate V). It was noted in sixty per cent of my cases. The en- 
largement of the abdomen is uniform. It is everywhere tympanitic, and 
it may be as tense as a drumhead. It is due to a loss of tone in the 
abdominal muscles, and in the muscular walls of the stomach and in- 
testine. It is aggravated by chronic indigestion and excessive intestinal 
putrefaction. The enlargement is thus mainly from tympanites. There 
may be a marked degree of dilatation both of the stomach and the colon. 
To a very small degree only, does the large abdomen depend upon swell- 
ing 'of the liver or spleen. 

The constipation of rickets, as already suggested, depends upon the 
loss of tone in the muscular walls of the intestines. It may alternate 
with diarrhoea. It rarely happens that a rachitic child has habitually 
normal evacuations from the bowels. Hard, dry, constipated stools fre- 
quently set up a condition of chronic catarrh of the colon in which large 
masses of mucus are discharged. 

Fever. — According to some observers there is a febrile movement 
which belongs to the active stage of rickets, but I have never been able to 
satisfy myself of the truth of this observation. 

Dentition. — As a rule, dentition is late and apt to be difficult, i. e., 
it is associated with attacks of indigestion or other disturbances which 
may be serious. Individual cases, however, present great variations in 
regard to this symptom. A study of the progress of dentition in one 
hundred and fifty rachitic children gave the following results: in fifty 
per cent the first teeth were cut on or before the eighth month; twenty 
per cent of the cases had no teeth at twelve months, and in eight per 
cent none had appeared at fifteen months. Even though the first teeth 



256 NUTRITION. 

come at the usual time, the progress of dentition is usually retarded by 
the development of rickets. The character of the teeth in rickets is 
usually good. This is in striking contrast to hereditary syphilis, where 
the tendency to early decay is constantly seen. 

General Appearance. — Children suffering from marked rickets 
are almost always anaemic. The majority are fat and flabby. The tissues 
are soft and have but little resistance. Rarely, they may be thin, like 
patients suffering from marasmus. 

Rachitic patients are very prone to suffer from hypertrophied tonsils, 
adenoid growths of the pharynx, and enlargements of the lymph nodes 
of the neck. ' In all forms of acute illness the feeble resistance of these 
patients is very evident. This is especially true of acute disease of the 
lungs. 

The mucous membranes are very vulnerable in all rachitic patients. 
From the slightest indiscretion in diet an attack of acute indigestion or 
diarrhoea may be brought on, and from a very insignificant exposure, 
catarrhal inflammation of the upper or lower air passages is excited. 
In rachitic patients all such attacks are prone to run a protracted course. 
Inflammation of the trachea and larger bronchi is likely to lextend to the 
smaller bronchi and the lungs. 

The downward displacement of the liver and spleen from contraction 
of the chest should not be mistaken for enlargement of these organs. 
Moderate enlargement of the spleen is very common during the stage 
of most active symptoms, i. e., from the sixth to the twelfth month. 
Great enlargement of either liver or spleen is infrequent. 

Blood. — Anaemia is present in most of the marked cases, its intensity 
varying with the severity of the rachitic process. The blood picture is 
usually that of an ordinary secondary anaemia. Leucocytosis is often 
present ; it is more marked in cases attended by an enlarged spleen. 

Nervous Symptoms are among the most frequent manifestations of 
rickets. Restlessness at night has already been mentioned as a prominent 
early symptom. Pain and tenderness are rare. A disposition to mus- 
cular spasm is seen in many cases. There may be laryngismus stridulus, 
tetany, or general convulsions. While in all infants, owing to the ir- 
ritability of the nervous centres, convulsions are easily excited from 
relatively slight causes, in those who are rachitic this susceptibility is 
greatly intensified. As a predisposing cause of convulsions in infancy, 
rickets takes the first place. The younger the child and the more active 
the rachitic process, the more frequently do convulsions occur. They 
belong especially to the first year, being most frequent between the third 
and sixth months. The exciting cause of convulsions in these cases is 
usually to be found in the stomach or intestine. 

Course and Termination. — Rickets is essentially a chronic disease, and 
its course is measured by months. The active symptoms in most cases 



RICKETS. 257 

continue from three to fifteen months. That active symptoms cease 
when a child reaches the age of eighteen months or two years, is no 
doubt due largely to the fact that at this age the diet is more general, 
and is more likely to furnish what the child needs, and that more fresh 
air is likely to be secured than at an earlier age. 

The earliest symptoms of improvement are a diminution in the 
nervous symptoms, especially in the restlessness at night; increased 
muscular power, as shown by a disposition to stand or walk ; diminution 
in the head-sweats ; disappearance of the cranio-tabes ; and improvement 
in the anaemia. The changes in the deformities are very slow, and from 
month to month almost imperceptible. When improvement once begins, 
however, it usually goes steadily forward. 

Types of Rickets. — Congenital Rickets. — Infants may present at birth 
the characteristic deformities of rickets, and there may be found even 
the minute bone changes of the disease. Such cases are reported to be 
common in Vienna and other large cities of Europe, where mothers dur- 
ing pregnancy have lived under unfavourable conditions. In America, 
however, congenital rickets is a very rare disease. Single cases have 
been reported by several writers ; but it must be remembered that cretin- 
ism and chondro-dystrophy have often been improperly included under 
this head. 

Late Rickets. — Rare instances have been reported of bony deformities 
in all respects like those of rickets, developing in children from six to 
twelve years old. A number of such cases have been observed in England. 
I have not seen this disease, nor has a case been seen during the past 
twenty years at the Hospital for Ruptured and Crippled, New York, 
where more deformities come under observation than anywhere else in 
this country. 

Acute Rickets. — Although from time to time cases have been reported 
with this title, from a study of the histories it is clear that the great 
majority, if not all of them, were cases of infantile scurvy. It is doubt- 
ful whether, strictly speaking, there is such a thing as acute rickets. 

Diagnosis. — The diagnosis of rickets is not usually difficult. The 
most important early symptoms for diagnosis are sweating of the head, 
cranio-tabes, great restlessness at night, delayed dentition, and enlarged 
fontanel. All these, taken separately, may mean something else, but 
collectively they can mean nothing but rickets. In the later stages some 
of the characteristic deformities are usually present; the most constant 
are beading of the ribs, enlargement of the epiphyses of the wrists and 
ankles, and bow-legs. 

Special symptoms, when unusually prominent, may give rise to diffi- 
culty in diagnosis. The enlargement of the head may be mistaken for 
hydrocephalus. The delayed dentition and large fontanel of the cretin 
may be mistaken for rickets. Muscular weakness may be so great, espe- 
18 



258 NUTRITION. 

cially when affecting the legs, as to make it easy to mistake a rachitic 
pseudo-paralysis for actual paralysis due to a cerebral or spinal lesion. 
When walking is much delayed, rickets may be passed over as simple 
backwardness. In nearly all of the last-mentioned group of cases the 
diagnosis may be cleared up by a careful search for the bony changes, 
and by the fact that in rickets there is only a general weakness of all 
the muscles, and not actual paralysis of any limb or group of muscles. 
The greatest difficulty is usually found where the muscular symptoms 
are marked and the bony changes slight, as is not infrequently the case. 
Here the question is, whether rickets is sufficient to explain all the symp- 
toms, or whether in addition some other condition is present. The 
electrical reactions will decide the question of poliomyelitis, while the 
presence of cerebral symptoms, exaggerated knee- jerks, and rigidity of 
the legs, will usually mark a cerebral birth-palsy. The bony enlarge- 
ments of syphilis may be confounded with those of rickets. The bone 
changes of early syphilis, although affecting the epiphyses are seen at 
an earlier age and are generally accompanied by pain and tenderness, 
sometimes by epiphyseal separation, none of which are seen in rickets. 
The bone changes of late syphilis affect the shaft rather than the ex- 
tremities of the long bones; where the bone is enlarged near the joint 
it is usually upon one side only. In syphilis there may be necrosis, while 
in rickets breaking down of bone is never seen. From scurvy, rickets is 
differentiated by the absence of marked hyperesthesia, ecchymoses, and 
other haemorrhages, the changes in the gums, and most of all by the 
fact that anti-scorbutic diet produces no immediate change in the symp- 
toms. The diagnosis of rachitic curvature of the spine from vertebral 
caries will be considered in connection with the latter disease. 

Prognosis. — Rickets per se is seldom, if ever, a cause of death. It 
is, however, a large factor in the mortality of the first two years, as it 
predisposes strongly to many forms of acute disease. It is an important 
etiological factor in certain serious nervous conditions, especially con- 
vulsions. Rickets adds very greatly to the danger from all acute diseases 
of infancy, particularly those of the respiratory tract. The encroach- 
ment upon the capacity of the lungs by a marked thoracic deformity, 
may in itself be enough to keep a child in a delicate condition and 
retard its growth. At the same time such a condition is a constant 
invitation to acute attacks of bronchitis or pneumonia. The effect of 
rickets upon the future health of the child depends chiefly upon the 
presence and extent of the thoracic deformity. When this is absent, 
although children may remain somewhat dwarfed on account of their 
short legs, in other respects they may be as well as if they had never 
been the subjects of rickets. 

Prophylaxis. — As rickets is primarily due to improper food or feed- 
ing, and secondarily to bad surroundings, it may largely be prevented 



RICKETS. 259 

by the observance of proper rules of feeding as laid down elsewhere, and 
by removing children from their faulty surroundings. Especial care 
should be given to the later children of a family where the earlier ones 
have shown even the mildest symptoms of rickets, as the predisposition 
is sure to increase with each successive child. 

Treatment. — In considering the treatment of rickets, the natural 
course of the disease is to be kept in mind, viz., that active symptoms 
frequently continue only until the end of the first year, rarely longer than 
the eighteenth or twentieth month. The most important period for 
treatment, therefore, and the one in which it is most effective, is from the 
sixth to the eighteenth month. The earlier the treatment is begun the 
better will be its results. General treatment after the eighteenth month, 
has very little effect upon the disease, for by this time most of the 
harm has been done. The course of the disease when untreated is toward 
spontaneous recovery, from the changes in diet and life which are usually 
made when children have reached the latter half of the second year. Most 
of the cases seen in private practice are of a mild type and recover 
without special treatment, often no diagnosis being made until later 
in life, when the bony deformities or stunted growth indicate the pre- 
vious existence of rickets. The first step in treatment is to remove the 
cause, and is therefore to be directed to the diet and hygiene of the 
patient. The results will depend upon how completely these causes can 
be discovered and removed. 

Diet. — Such disorders of digestion as are present must be treated 
on general principles. The most frequent dietetic error in rachitic 
patients being an excess of carbohydrates and an insufficient supply of 
fat, it follows that condensed milk, proprietary infant foods, and large 
amounts of farinaceous foods of every description should be stopped. A 
suitably modified cow's milk should be substituted or for young infants 
a wet-nurse should be secured. Most infants, however, are eight to ten 
months old before rachitic symptoms are observed; to them beef juice, 
raw eggs, and fruit juice should be given in addition to milk. Cream, 
though desirable, is very often badly borne and some other form of fat 
must be substituted. For many infants olive oil will be found useful 
and may be given, one teaspoonful three times a day for long periods. 
The fat of crisp bacon upon stale bread or zwieback among the poor 
may serve as well. All these articles are to be given according to the 
rules laid down in the chapters on Infant Feeding. 

Hygiene. — In large cities it is almost impossible to secure for rachitic 
patients the surroundings they require. Whenever possible, such chil- 
dren should be sent to the country ; but where this is out of the question, 
much may be accomplished by frequent excursions upon the water or 
into the country, by keeping children as much as possible in the parks 
and open squares of the city, and securing plenty of fresh air in sleeping 



260 NUTRITION. 

rooms. Cold sponge-baths given every morning, do much to lessen this 
susceptibility. Sunshine, though difficult to obtain in large cities, is a 
most efficient therapeutic agent. The establishment of suburban hospitals 
and homes for these cases would do more than anything else to lessen 
the mortality from rickets. 

Medicinal Treatment. — In a disease which tends so uniformly to 
recovery when causal conditions are removed, it is difficult to estimate, 
by clinical observations, the real value of medicinal treatment. Arsenic 
and iron are valuable in the treatment of rickets, the special indication 
for their use being the presence of marked anaemia. Profuse sweating 
may be relieved by small doses of atropine, i. e., gr. -g-l-^, three or four 
times a day, to a child of six months. The special remedies most used 
are cod-liver oil, phosphorus, and preparations of calcium. 

The various preparations of calcium, the phosphate, lactophosphate, 
and hypophosphite, have long been employed with the belief that they 
could supply lime to the tissues. It is now practically certain that they 
do not do so, although at times, they may be useful as tonics in this con- 
dition. The two important remedies for rickets are cod-liver oil and 
phosphorus. No remedy for rickets has held its place so long as has 
cod-liver oil. Phosphorus, popularised in the treatment of this disease 
by Kassowitz, has also some value; its most striking results are seen in 
the early cases and when nervous symptoms are marked. The best results 
are obtained by a combination of these two remedies. The officinal oil 
of phosphorus is used in combination with cod-liver oil, gr. yj^ to ^J-5- 
is given three times a day with one-half drachm to one drachm of the oil. 
Striking confirmation of the clinical observations regarding the value 
of this combination is furnished by the metabolism experiments of 
Schabad who found the percentage of calcium retention enormously in- 
creased by the use of cod-liver oil and phosphorus. 

Treatment of the Rachitic Deformities. — The deformities of the 
chest are less amenable to treatment than most of the others. After the 
third year something can be done by gymnastics to develop the chest 
muscles and to increase the pulmonary expansion. The employment of 
the pneumatic cabinet, in which it is sought to overcome these deform- 
ities by the use of rarefied air, has never been given the trial which it 
deserves. From the very meagre reports published, this appears to be 
of considerable value. 

The deformity of the spine (kyphosis) may usually be overcome by 
postural treatment. The patient should lie upon a hard bed; no pillow 
should be allowed under the head, but in severe cases one should be 
placed beneath the back, so that the head and buttocks are slightly lower 
than the lumbar spine. While sitting, the shoulders should be kept back 
and the trunk supported. For a few minutes each day the child should 
be placed upon the face, and the deformity overcome by raising the but- 



RICKETS. 261 

tocks while pressure is made upon the spine. In severe cases, an 
apparatus for giving spinal support, either by a steel brace or a plaster- 
of-Paris jacket, may be worn a few hours each day when the child is 
sitting up. Other means should be employed, especially friction and 
massage, to develop the spinal muscles. 

In very many cases slight deformities of the extremities are outgrown 
when the general treatment can be properly carried out. Where these 
exist, the physician should take the curve of the legs by seating the 
child upon a flat surface and tracing their outline with a pencil held 
perpendicularly. A fresh tracing should be taken once a month. If the 
deformity is not very great and no increase takes place, it is safe to 
continue with general treatment only. If the deformity is marked or if 
it increases in spite of the constitutional treatment, braces should be 
applied. Something may be done toward straightening the bones by 
intelligent manipulation. "Walking should be discouraged until the bones 
are quite firm. Friction of the extremities and massage will do very 
much to increase muscular development. The habit of sitting cross- 
legged — a very common one in rachitic children — should be prevented, 
and in fact any other habitual posture, on account of the danger of 
increasing certain deformities. But little is to be expected from the 
use of apparatus for the correction of rachitic deformities after the child 
is two and a half years old; since at this time, and often even at two 
years, the bones are so firm that no amount of pressure from a steel 
brace will have any effect. 

Without going fully into the question of the surgical treatment of 
rachitic deformities, for which the reader is referred to text-books of 
general and orthopaedic surgery, I will only state that osteotomy seems 
to me to offer decided advantages over the other means of treating severe 
deformities. The best results in osteotomy are obtained when the opera- 
tion is delayed until the fourth or fifth year, by which time the bones are 
sufficiently firm and solid. Operations in the second year are generally 
unsatisfactory, and those in the third year often so, because of the bend- 
ing of the bones which takes place subsequently. The deformities which 
require operation are bow-legs and knock-knees, less frequently the cur- 
vatures of the femur of the bones of the forearm. 



SECTION III. 
DISEASES OF THE DIGESTIVE SYSTEM. 

CHAPTER I. 
DISEASES OF THE LIPS, TONGUE, AND MOUTH. 

MALFORMATIONS. 

Harelip. — This is one of the most frequent congenital deformities. 
It is caused by an incomplete fusion of the central process with one or 
both of the lateral processes from which the upper half of the face is de- 
veloped. This deformity may be single or double ; the fissure is never in 
the median line, but usually just beneath the centre of the nostril. There 
may be simply a slight indentation in the lip, or the fissure may extend 
to the nostril. Both single and double harelip — more frequently the lat- 
ter — may be complicated by fissure of the palate. Double harelip is 
usually accompanied by a fissure between the intermaxillary and the 
superior maxillary bone of each side. 

Cleft Palate. — This is second in frequency to harelip. It may involve 
the soft palate only, or the fissure may extend into the hard palate, pro- 
ducing a wide gap in the roof of the mouth. The most frequent form 
is that in which only the soft palate is affected. 

For the surgical treatment of both these deformities the reader is re- 
ferred to text-books upon surgery. As to the time of operation, in cases 
of harelip with a vigorous child of. eight or nine pounds, operation in 
the early days of life is to be preferred. With a small and delicate infant 
it is best to wait until it is well started in its growth — usually the sec- 
ond month — and in cleft palate during the second year. The medical 
treatment of these cases consists in the care of the mouth and in the 
nutrition of the patient. The mouth in all cases must be kept scrupu- 
lously clean, but the greatest care is necessary not to injure the epi- 
thelium. A camelVhair brush and plain lukewarm water, or a weak 
alkaline solution, are to be recommended. Both these deformities are 
exceedingly likely to be complicated by thrush. This is a serious menace 
to the success of any operation, and even to the life of the patient. The 
nutrition is always a matter of much difficult}^, and a very large number 
of these cases die of inanition or marasmus. In cases of harelip, if the 
262 



DISEASES OF THE LIPS. 263 

fissure is so great as to interfere with nursing, the child may be fed 
with a spoon or a medicine dropper until the operation can be done. 
In cleft palate there may be attached to the rubber nipple of the nursing 
bottle a flap of thin sheet-rubber in such a way that it closes the fis- 
sure in the mouth when once the nipple is in place. This flap should be 
shaped like a leaf, one extremity being sewed to the neck of the rubber 
nipple and the other end left free. In many cases, both before and 
immediately after operation, gavage may be resorted to with the greatest 
benefit and with very little inconvenience. 

Congenital Hypertrophy of the Tongue. — This is usually due to dis- 
ease of the lymphatics, and is to be regarded as a lymphangioma. In a 
few cases hypertrophy of the muscular fibres has been present. The 
tongue may reach an enormous size, so that it is impossible for it to be 
contained within the cavity of the mouth, and it may thus interfere with 
nursing, deglutition, and even with respiration. The treatment is sur- 
gical. Cases like the above are to be distinguished from those of enlarge- 
ment of the tongue seen in sporadic cretinism. In this disease the 
tongue is considerably enlarged and may protrude slightly from the 
mouth, but it is rarely, if ever, large enough to cause other symptoms. 
It diminishes notably under treatment with thyroid extract. 

Bifid Tongue. — These cases are extremely rare. Brothers has re- 
ported to the New York Pathological Society a case of cleft tongue in a 
child of one month. There was, in addition, a fissure of the soft palate. 

Tongue-tie. — This deformity is due to such a shortening of the fre- 
num that it is impossible to protrude the tongue to a normal extent. It 
differs considerably in degree in different cases. In some, the tongue 
can not be protruded beyond the gums. Tongue-tie may interfere with 
articulation, and even with sucking. The treatment consists in liberat- 
ing the tongue by dividing the frenum with scissors and completing the 
operation with the finger nail. This should be done in every case unless 
the child is a bleeder. In many cases the mother may think the tongue 
tied when the frenum is of normal length. 

Bifid Uvula. — This is not very uncommon. It usually occurs in con- 
nection with cleft palate, but is occasionally seen when there is no other 
deformity present. It may be complete or partial, and it does not of it- 
self require treatment. 

DISEASES OF THE LIPS. 

Herpes. — Herpes labialis is an exceedingly common affection in chil- 
dren, occurring in acute febrile diseases, particularly pneumonia, and 
sometimes alone. It is the familiar "fever sore" or "cold sore" of 
domestic medicine. The appearance is similar to herpes in other parts 
of the body. There is first a group of vesicles, then rupture and the 
formation of crusts. It is often quite difficult to cure on account of the 



264 DISEASES OF THE DIGESTIVE SYSTEM. 

disposition of children to pick the lip with the fingers. Although it heals 
without treatment, recovery is facilitated by the use of some antiseptic 
lotion, such as dilute boric acid, followed by a dusting powder of zinc 
oxide and boric acid. This treatment is generalty more successful than 
the use of ointments. Young children should wear mittens or elbow 
splints at night, to prevent picking at the crusts. 

Eczema of the Lip. — This is an exceedingly common condition, and 
a very troublesome one. The vermilion border is dry and rough, and 
prone to deep cracks or fissures. These are usually seen at the angles of 
the mouth or in the median line. When severe they are exceedingly 
painful, bleed freely, and are the cause of very great discomfort, es- 
pecially in the cold season. The lips should be covered at night by a 
simple ointment, and this should be used as much as possible during the 
day. Where deep fissures form, they should be touched with burnt alum, 
or with the solid stick of nitrate of silver. Syphilitic fissures are con- 
sidered with the symptoms of that disease. 

Perleche (French, perlecher = to lick). — This name was first given 
by Lemaistre, in 1886, to a form of ulceration occurring usually at the 
angle of the mouth. It begins in most cases as a small fissure, which, by 
constant licking and irritation, to which there is usually added infection, 
may produce an intractable ulcer of considerable size. It often resem- 
bles the mucous patch of hereditary syphilis. The ulcer is of a grayish 
colour, is quite painful, and is associated with considerable swelling of 
the lip. It lasts from two to four weeks. The treatment is the same as 
in simple fissure — viz., the use of burnt alum or nitrate of silver, and 
covering the part with bismuth or oxide of zinc. 

DISEASES OF THE TONGUE. 

Epithelial Desquamation. — This is a disease of the lingual epithe- 
lium, which is characterised b}^ the appearance upon the dorsum or 
margin of the tongue, of circular, elliptical, or crescentic red patches, 
with gray margins which are slightly elevated. The gray margins are 
apparently due to thickening of the epithelial layer and the red areas 
to desquamation of the epithelium. It is sometimes improperly called 
psoriasis of the tongue. It is quite a common condition, and is prob- 
ably congenital. 

As usually seen, there exist upon the tongue from two to half a dozen 
of these red patches surrounded by a gray border, which is about one- 
twelfth of an inch wide, and slightly elevated. The outline of the patch 
is nearly always crescentic (see Fig. 44). From day to day the con- 
figuration of the patches changes; the gray lines advance across the 
tongue from side to side, or from base to tip, disappearing as they reach 
the border or the extremity. They are followed by the red patches, 



DISEASES OF THE TONGUE. 



265 




Fig. 44. — Epithelial Desqua- 
mation of the Tongue. 
(Guinon.) 



and as the old ones fade away new ones form and run the same course. 
The red patches are of a bright colour nearest the border, gradually 
shading off into the normal colour of the tongue. Only the epithelium is 
involved, the deeper structures being unaf- 
fected. The duration of the disease is indefi- 
nite; it usually lasts for years. Guinon 
reports several cases which recovered dur- 
ing an intercurrent attack of measles or 
scarlet fever. 

The cause is unknown. The condition 
occurs rather more frequently in females 
than in males, and Gubler has reported an 
instance of several members of the same 
family being affected. The condition has 
been thought to depend upon nearly every 
disease of childhood. It is not accom- 
panied by pain, salivation, or by other symp- 
toms of stomatitis, and is of little practical 
importance. Its symptoms are so charac- 
teristic that it can hardly be mistaken for any other condition. Treat- 
ment is unnecessary. 

Two other forms of epithelial desquamation have been observed, 
both much more rare than that described. In one of these the red de- 
nuded portion occupies the margin of the tongue, while the centre is 
gray or white; the irregular wavy outline which separates the two sug- 
gests strongly an outline map, and the condition is sometimes called the 
"geographical tongue." This term is frequently employed to designate 
the common form. In another variety nearly the whole organ may be 
uniformly red, from loss of the epithelium, there being no borders or 
patches. Both these varieties are of much shorter duration than the 
more common form, usually lasting only a few weeks. 

Glossitis. — Inflammation of the tongue is not very common in chil- 
dren. It is usually of traumatic origin. The injury may be due to bit- 
ing the tongue in a fall or in an epileptic seizure. Glossitis is sometimes 
excited by the irritation of a sharp tooth, causing a wound which may be 
the avenue of infection; or it may result from taking into the mouth 
irritant or caustic poisons. In a small number of cases no cause can be 
found. The symptoms are marked swelling of the tongue, so that it may 
protrude from the mouth ; and it may even be so great as to cause severe 
dyspnoea. There are also profuse salivation, difficulty in swallowing and 
in articulation, and often considerable local pain. There may be a 
rise of temperature to 102° or 103° F. The treatment consists in the 
use of fluid food, which in severe cases may be introduced through 
the nose by means of a catheter. Ice may be used externally, or, bet- 



266 DISEASES OF THE DIGESTIVE SYSTEM. 

ter still, pieces of ice may be kept in the mouth continually. If there 
is obstruction to respiration, and in all severe cases, scarification should 
be done on the dorsum of the tongue along the side of the raphe. 

The acute swelling of the tongue and lips occurring in some cases of 
urticaria may be mentioned in this connection. This is a rare condi- 
tion in children, but it may develop rapidly and to such a degree as to 
cause alarming symptoms. The treatment consists in the use of ice 
locally, free purgation by salines, and, in extreme cases, needle punc- 
tures to relieve the oedema. 

Tongue-swallowing. — This term is used to describe a rare condition 
seen in infants, in which the tongue is turned backward into the 
pharynx, so as to obstruct respiration. It may be drawn quite into 
the oesophagus. Several marked cases have been collected by Hennig. 1 
While most frequently occurring with paroxysms of pertussis, tongue- 
swallowing has been seen in other diseases. This should not be forgot- 
ten as one of the explanations of sudden asphyxia in a young infant. 
The conditions necessary for its production are a somewhat relaxed organ 
or a long frenum. In none of the fatal cases reported, however, had the 
frenum been divided. In some weak infants, falling back of the tongue, 
so that its base partly covers the epiglottis, produces asphyxia, precisely 
as it occurs in adult life under full anaesthesia. The recognition of the 
condition is a very easy one, and its treatment is to relieve the obstruc- 
tion by drawing the tongue forward by the finger or forceps. 

Ulcer of the Frenum. — The friction against the sharp edges of the 
lower central incisors frequently causes an ulcer of the frenum in in- 
fants. I have never seen it in older children. It usually occurs in 
pertussis, but is seen in other conditions. In some it appears to be pro- 
duced by friction of the teeth during nursing from the breast or bottle. 
It is more often seen in children who are delicate or cachectic than in 
those who are healthy and well nourished. The ulcer may be confined 
to the frenum, or it may extend quite deeply into the tongue. It is 
usually about one-fourth of an inch in diameter, and of a yellowish-gray 
colour. When not readily cured by touching with alum or nitrate of 
silver, the child may be fed by gavage for several days, or the teeth may 
be covered by a bit of absorbent cotton. 

DENTAL CARIES. 

Although the teeth do not strictly belong to the province of the physi- 
cian they have an important influence upon the general health. The 
pernicious effects of dental caries have only recently been appreciated. 
Routine examinations of public-school children, made in various cities, 
have shown that fully 80 per cent have extensive dental caries. Among 

1 Jahrbuch fur Kinderheilkunde, xi, 299. 



ALVEOLAR ABSCESS. 267 

the inmates of institutions the proportion is fully as great as this, possi- 
bly greater, unless, as in a few modern institutions, special attention is 
given to this subject. 

Among the causes of dental caries the most important without doubt 
is want of cleanliness — the almost entire neglect of the toothbrush 
among the children of the poor. This leads to decomposition of food 
and secretions, acid fermentation, erosions of the enamel, etc. But not 
all caries of the teeth can be ascribed to this cause. Diet has certainly 
much to do with it. It is my own belief that the opinion commonly held, 
that excessive indulgence in sweets is responsible for dental caries, is 
well founded. Malnutrition and improper food, especially in early 
childhood, certainly affect the teeth. In some children a congenitally 
defective enamel is present. Hereditary syphilis is also a cause, and in 
children with congenital mental defects the teeth are prone to early 
decay. 

The symptoms are both local and general. Locally, as a result of 
decomposition and infection, there are present foul breath, gingivitis, 
alveolar abscess, ulcerative stomatitis, toothache, etc. The lymph nodes 
in the neighbourhood frequently become enlarged and sometimes tuber- 
culous. The tuberculosis of the submaxillary and submental lymph 
nodes is nearly always the result of infection through the teeth or the 
gums. Whether the cervical lymph nodes are infected in the same way 
is very doubtful. The general symptoms result in part from improper 
mastication of food and in part from sepsis from the local condition. 
Thus we may have attacks of indigestion, failing nutrition, loss of appe- 
tite, and anaemia. From the local irritation various nervous symptoms 
may arise. The most common are habit spasm, facial chorea, headaches, 
and according to some writers even epileptiform convulsions. The pres- 
ence of carious teeth is a menace to the general health. They certainly 
predispose to local tuberculosis. Many persons assume that if the teeth 
affected belong to the first set, it matters little. However, the perma- 
nent teeth are often injured by extensive decay of the deciduous set. 
The treatment of this condition belongs to the dentist. But the physician 
should appreciate the importance of the subject and urge parents and 
others in charge of children to give proper attention to cleanliness and to 
see that carious teeth of the first set are either filled or removed. 



ALVEOLAR ABSCESS. 

This is common in children, especially among the class of hospital 
and dispensary patients, in whom little or no attention is given to the 
care of the teeth. It causes severe pain and acute swelling, which may be 
limited to the gum, or it may involve to a considerable extent the perios- 
teum of the jaw and even cause swelling of the whole side of the face. 



26S DISEASES OF THE DIGESTIVE SYSTEM. 

If there is retention of pus, there may be quite severe constitutional 
symptoms, such as a chill and high temperature; but in most of the 
cases these are wanting. The abscess usually opens spontaneously into 
the mouth, but it may open externally if the molar teeth are the ones 
affected. It may even lead to necrosis of the jaw. If its site is the upper 
jaw, the pus may find its way into the nasal cavity or into the maxillary 
sinus. 

The treatment is, in the first place, prophylactic. This requires atten- 
tion to the teeth to prevent decay, and the removal of old carious fangs, 
which are a constant menace to the health of the child. The free use 
of the toothbrush and some antiseptic mouth-wash will, in the great 
majority of cases, prevent the occurrence of this disease. It is impor- 
tant that the abscess be opened early and free drainage secured. If 
there is a carious tooth it should be drawn. 



DIFFICULT DENTITION. 

The place of dentition as an etiological factor in the diseases of in- 
fancy is one which has given rise to much discussion. From a very early 
period the view has descended, that a large number of the diseases occur- 
ring between the ages of six months and two years are due to difficult 
dentition. The list of such diseases is a long one, but year by year it has 
been shortened as one after another has been shown to depend upon 
other causes, dentition being only a coincidence. 

At the present time many good observers deny that dentition is ever 
a cause of symptoms in children; some even going so far as to say that 
the growth of the teeth causes no more symptoms than the growth of the 
hair. Without doubt the usual mistake made in practice is to overlook 
disease of the brain, ears, lungs, stomach, and intestines, because of the 
firm belief that the child was " only teething/' The physician who 
starts out with the idea that in infancy dentition may produce all symp- 
toms usually gets no further than this in his etiological investigations. 
Although no doubt the importance of dentition as an etiological factor 
in disease has been in the past greatly exaggerated, the careful and 
candid observer must admit that, particularly in delicate, highly nervous 
children, dentition may produce many reflex symptoms, some even of 
quite an alarming character. 

Speaking from general impressions not from statistics, I should say 
that in my experience fully one-half of the healthy children cut their 
teeth without any visible symptoms, local or general; in the remainder 
some disturbance is usually seen, and though in most cases it is slight 
and of short duration, it may last for several days or even a week. The 
symptoms most commonly seen are disturbed sleep, or wakefulness at 
night and fretfulness by day, so that children often sleep only one-half 



DIFFICULT DENTITION. 269 

the usual time. There is loss of appetite, and much less food than usual 
is taken. There is often, but not always, an increase in the salivary 
secretion, a slight amount of catarrhal stomatitis, and a constant dispo- 
sition on the part of the child to put the fingers into the mouth. The 
bowels are often constipated or there may be slight diarrhoea. The ther- 
mometer may show a slight elevation of temperature to 100° or 101.5° 
F. The weight often remains stationary for a week or two, and there 
may even be a loss of a few ounces. The duration of these symptoms in 
most cases is but a few days, and they require no special treatment. If 
the food is forced beyond the child's inclination, attacks of indigestion 
with vomiting and diarrhoea are easily excited. 

Symptoms more severe than the above, are rare in healthy children, 
but are not infrequent in those who are delicate or rachitic. In such 
susceptible children, even so slight a thing as dentition may be an excit- 
ing cause of quite serious disturbances. Often there is some other 
factor in the case, such as bad feeding or feeble digestion. In delicate 
or rachitic children there may be seen the symptoms already mentioned 
as occurring in healthy infants, but in greater severity; and in addition 
there may be severe attacks of acute indigestion. Occasionally there is 
an elevation of temperature to 102° or 103° F., lasting usually only two 
or three days, and accompanied by no symptoms except almost complete 
anorexia. Convulsions which could fairly be attributed to dentition I 
have seen but two or three times ; they are more apt to occur in rachitic 
and highly nervous children. In cases of eczema the symptoms often 
undergo a distinct exacerbation with the eruption of each group of 
teeth. As regards almost all the other diseased conditions which are 
commonly attributed to dentition, I believe that it is a delusion to ascribe 
them to this cause. 

The physician should watch a child carefully, and examine it fre- 
quently, to be sure that he is not overlooking some serious local or con- 
stitutional disease before he allows himself to make the diagnosis of 
difficult dentition. Probably in ninety-five per cent of the cases in which 
symptoms are present, they are due to some cause other than dentition. 
When, however, symptoms such as any of those mentioned disappear 
immediately when the teeth come through, and when we see them 
repeated four or five times in the same child with the eruption of each 
group of teeth, and accompanied by red and swollen gums, I think we 
can not escape the conclusion that dentition is a factor in their pro- 
duction, though perhaps not the only one. 

In the treatment of this condition drugs occupy but a small place. It 
should be remembered that infants are at this time in a peculiarly sus- 
ceptible condition as regards the digestive tract, and attacks of indiges- 
tion, and even severe diarrhoea, are readily excited from slight causes, 
especially from overfeeding. Special care should be exercised in this 



270 DISEASES OF THE DIGESTIVE SYSTEM. 

respect. The strength of the food should be reduced, as well as the 
amount given. A poor appetite indicates a feeble digestion, which 
should not be overtaxed. As attacks of bronchitis and acute nasal ca- 
tarrh are readily induced, even slight exposure should be guarded 
against. The nervous symptoms, when severe, may be relieved by the 
use of moderate doses of the bromides or by phenacetine, better than by 
opiates. All soothing syrups should be discountenanced. All the vari- 
ous devices for making dentition easy are a delusion. In a small num- 
ber of cases lancing the gums is of value. I have myself seen in a few 
rare instances marked and undoubted relief given by it. This is likely 
to be the case where the gums are tense, swollen, and very red, with the 
teeth just beneath the mucous membrane. To press a tooth through the 
gum by simply rubbing gently with, the ringer covered with sterile gauze 
is frequently more effective than an incision. It is seldom, however, 
that the relief expected is seen from any of these measures. 



CATARRHAL STOMATITIS. 

This is characterised by redness and swelling of the mucous mem- 
brane, and by increased secretion of the salivary and the muciparous 
glands of the mouth. It usually involves a large part of the mucous 
membrane. 

Etiology. — Catarrhal stomatitis may result from traumatism. This 
injury may be mechanical, or due to heat or any irritant accidentally 
taken into the mouth. It frequently occurs at the time of the eruption 
of a tooth. It complicates measles, scarlet fever, diphtheria, influenza, 
and many other infectious diseases. In these cases, and in many others, 
the disease is probably due to direct infection. 

Lesions. — The lesions are essentially the same as in catarrhal inflam- 
mations of other mucous membranes. There are congestion with des- 
quamation of epithelial cells, and sometimes the formation of superficial 
ulcers. The process may be a very superficial one, or it may extend to 
the submucous tissue. 

Symptoms. — The mucous membrane is intensely injected, all the 
capillaries are dilated, and small haemorrhages easily excited. The mu- 
cous membrane is swollen, this being most apparent over the gums or 
about the teeth. There may be some swelling of the lips. The mouth 
seems hot, and the local temperature is certainly increased. There is 
considerable pain, as shown by fretfulness, but particularly by the disin- 
clination to take food: infants, though evidently hungry, either refusing 
the breast or bottle altogether, or dropping it after a few moments. The 
increase in secretion is sometimes marked, so that the saliva pours from 
the mouth, irritating the lips and face and drenching the clothing. In 
other cases the saliva is swallowed. On close inspection there may be 



HERPETIC STOMATITIS. 271 

seen swelling of the muciparous follicles, and even the formation of tiny 
cysts from the accumulation of secretion within them. The tongue is 
usually coated, the edges reddened, and the papillae prominent. In 
febrile diseases, such as typhoid, etc., we may get an accumulation of 
dead epithelium with the formation of cracks and fissures of the tongue, 
and the lips may present a similar condition. The neighbouring lym- 
phatic glands are slightly enlarged and tender. The constitutional symp- 
toms accompanying simple stomatitis are not severe, but some disturb- 
ance is almost always present. There may be derangement of digestion 
with vomiting, and even a mild attack of diarrhoea. In the majority of 
cases the disease runs a short course, recovery taking place in a few 
days when the primary cause is removed. In very delicate children it 
may be prolonged, and from the interference with nutrition may even 
lead to serious consequences. 

Treatment. — The mouth and teeth should be kept clean. Food is 
more acceptable if given cold. In very severe cases, where food is refused, 
gavage may be resorted to three or four times daily. In all cases chil- 
dren may be given ice to suck. This is refreshing, both on account of 
the cold and from the relief to the thirst. The mouth should be kept 
clean with a solution of boric acid, ten grains to the ounce, or an alkaline 
solution, such as DobelPs, diluted with an equal amount of cold boiled 
water; or plain water may be used. In the severe forms, where there is 
much swelling and slight catarrhal ulceration, astringents are required. 
In my experience alum is the best; this may be applied in the form of 
the powdered burnt alum mixed with an equal amount of bismuth, or in 
solution, ten grains to the ounce, with a swab or brush. Where ulcers 
are slow in healing and very painful, the powdered burnt alum or the 
solid stick of nitrate of silver may be applied directly. 

HERPETIC STOMATITIS. 

(Aphthous, Vesicular, or Follicular Stomatitis.) 

In this form of stomatitis we have the appearance first of small 
yellowish-white isolated spots, and subsequently the formation of super- 
ficial ulcers. These ulcers are first discrete, but may coalesce and form 
others of considerable size. It is a self-limited disease, usually running 
its course in from five days to two weeks. 

Etiology. — Very little is as yet positively known regarding the cause 
of herpetic stomatitis. It is not common in the first year, but after that 
is very frequently seen throughout childhood. It occurs in the strong as 
well as in the delicate. It is often associated with some disturbance of 
the stomach, and occasionally with dentition. I have adopted the term 
herpetic because the condition is analogous to herpes of the lips and 
face, the difference in appearance being due chiefly to location. It is 



272 DISEASES OF THE DIGESTIVE S^ 

apparently caused by something which ads upoi 
ments. 

Lesions. — The generally accepted opinion is th 
cle, followed by a death of epithelial cells covering 

ficial ulcer. The white appearance is due to the idu mat niv. lU^i*, 
being on a mucous membrane, are always moist. These ulcers may 
extend superficially, but never deeply; they heal quickly with the for- 
mation of new epithelial cells, leaving no cicatrices. Herpetic stoma- 
titis is always associated with more or less catarrhal inflammation. 

Symptoms. — The disease is characterised by local and general symp- 
toms. The latter are quite indefinite — general indisposition, loss of 
appetite, and slight fever. The local symptoms consist in the develop- 
ment of small, shallow, circular ulcers, usually coming in successive 
crops. While most frequent at the border of the tongue and the inside 
of the lips, they may be found upon any part of the mucous membrane 
of the mouth or the pharynx. There may be only half a dozen present, 
or the mouth may be filled with them. They are first of a yellowish 
colour, and on an average about one-eighth of an inch in diameter. By 
the coalescence of several smaller ones there may form patches of con- 
siderable size, sometimes nearly covering the lips. The older ulcers are 
apt to have a dirty grayish colour, and in places may look not unlike a 
diphtheritic membrane. The smaller ones are surrounded by a red 
areola, and when healing the margin is of a bright red colour. Their 
appearance is often more like that of an exudation upon the mucous 
membrane than an excavation into it. The other symptoms are much 
the same as those of catarrhal stomatitis, but usually of greater severity. 
The pain is particularly intense, it being often difficult to induce chil- 
dren to take anything in the form of food. The tongue is frequently 
coated, but there is never the foul breath of ulcerative stomatitis. The 
duration of the disease is from one to two weeks, and, if the child is in 
good condition, complete recovery takes place even without any special 
treatment. In badly nourished children the disease may last for two or 
three weeks; relapses may occur, and the condition may interfere v< :y 
seriously with the child's nutrition. 

Treatment. — This is the same as in catarrhal stomatitis, with the 
addition that to each one of the ulcers finely powdered burnt alum should 
be applied with a camel's-hair brush. If this is not effective, the solid 
stick of nitrate of silver may be used. The ulcers will usually yield rap- 
idly to this treatment. In my experience, drugs given with the purpose 
of affecting the lesion in the mouth have been without benefit. 

ULCERATIVE STOMATITIS. 

Ulcerative stomatitis is believed to occur only when teeth are pres- 
ent. It is characterised by an ulcerative process, beginning at the June- 



ULCERATIVE STOMATITIS. 273 

tion of the teeth and the gum, and extending along the teetli ; it occa- 
sionally involves other parts of the mouth, but never spreads beyond the 
buccal cavity. 

Etiology. — A form of ulcerative stomatitis is produced by certain 
metallic poisons, especially mercury, lead, and phosphorus ; but all these 
are now rare. Ulcerative stomatitis also occurs in scurvy; and it seems 
probable that an allied disturbance of nutrition, with spongy, swollen 
gums, precedes some other forms of ulcerative stomatitis. Bad sur- 
roundings and improper food act as predisposing causes; for the disease 
is quite common in institutions for children and in hospital and dis- 
pensary patients, although rare in private practice. Local causes of im- 
portance are want of cleanliness of the mouth and teeth and the presence 
of carious teeth. Conditions which produce a lowered vitality of the 
gums act as a predisposing cause, and infection as an exciting cause of 
the disease. The constant clinical features of ulcerative stomatitis and 
the occasional occurrence of epidemics indicate a specific cause which is 
probably the same as that of ulcero-membranous tonsillitis. The two 
conditions often exist at the same time. From the investigations of Vin- 
cent, Bernheim, Plaut and others it seems probable that noma is also 
produced by the same organism but represents a more virulent infection. 

Lesions. — The disease may begin at any part of the mouth, but most 
frequently upon the outer surface of the gum along the lower incisor 
teeth. From this point it extends behind the teeth, and from the in- 
cisors to the canines and molars, usually of one side only; but it may 
involve the entire gum of both jaws. From the gums the process may 
spread to the lips, affecting the fold of mucous membrane between the 
gum and the lip, and also to the inner surface of the cheek, especially 
opposite the molar teeth, where large ulcers often form. In neglected 
cases the disease may extend into the alveolar sockets, the teeth loosen- 
ing and falling out. The periosteum of the alveolar process may be in- 
volved, and even superficial necrosis of the jaw may occur, as has hap- 
pened in several cases that came under my observation. These severe 
forms are met with in institutions chiefly and then generally follow 
measles or scarlet fever. 

Ulcers similar in appearance may also be present in other parts of 
the mouth — i. e., on the soft palate or the tonsils, sometimes even when 
the gums are not involved. 

Symptoms. — The first things noticed are the very offensive breath 
and the profuse salivation. It is usually for one of these symptoms that 
the patient is brought for treatment. On inspection of the mouth, there 
are seen in the mild cases, swollen, spongy gums of a deep-red or purplish 
colour, which bleed at the slightest touch. There is a line of ulceration, 
usually along the incisor teeth, most marked in front, which may ex- 
tend to any or to all of the teeth; sometimes it affects only the gum 
19 



274 DISEASES OF THE DIGESTIVE SYSTEM. 

along the molar teeth, the incisors escaping. At the junction of the 
teeth and gum is seen a dirty, yellowish deposit, on the removal of which 
free bleeding takes place. The diseased parts are very painful, and the 
child cries and resists any attempt at examination. In the more severe 
cases and in those of longer duration the teeth are loosened, sometimes 
being so loose that they can be picked from the gum. There may be 
necrosis of the jaw, and even a loose sequestrum may be found. In 
these cases the ulceration along the gums is deeper, and there may be 
ulcers in the cheek opposite the molar teeth, or inside the lip. The 
swelling may be so great that the teeth are almost covered; this is seen 
particularly in the scorbutic form. The saliva pours from the mouth, 
adding greatly to the discomfort of the patient. Beneath the jaw are 
felt the large, swollen lymphatic glands, which are painful and tender to 
the touch, but show no tendency to suppurate. The tongue is somewhat 
swollen, and shows at the edges the imprint of the teeth; it has a thick, 
dirty coating. 

The disease is attended by little or no fever or other constitutional 
symptoms. The general condition of these patients is often poor, and 
there may be quite a marked cachexia. Other forms of stomatitis may be 
associated, and it should not be forgotten that the gangrenous form may 
follow. 

When not recognised or not properly treated, ulcerative stomatitis 
may last for months. When properly treated it tends in all recent cases 
to recovery, usually in from five to ten days. Xo deformity of the mouth 
is left, the only untoward results being shrinking of the gum, sometimes 
loss of some of the incisor teeth, and more rarely a superficial necrosis 
of the alveolar process. All these are quite uncommon. Ulcerative 
stomatitis can hardly be confounded with any other form, and not only 
should a diagnosis of the lesion be made, but the condition upon which 
it depends should, if possible, be discovered; scorbutus, particularly, 
should not be overlooked. 

Treatment. — The first thing to be done is to remove the cause. When 
dependent upon metallic poisoning the source should be discovered. 
Scorbutic cases should have the usual anti-scorbutic diet. Cleanliness of 
the mouth is of great importance, and this may best be accomplished by 
the use of peroxide of hydrogen diluted with from one to four parts of 
water. It should be followed by thorough rinsing with plain water, and 
repeated several times a day. In other cases a solution of alum, five 
grains to the ounce, or a mouth-wash of chlorate of potash, three grains 
to the ounce, may be employed. The only objection to the last men- 
tioned is the pain which it usually produces. 

The specific remedy for ulcerative stomatitis is chlorate of potash. 
The best method of administration is to give two grains, or one-half tea- 
spoonful of a saturated solution, largely diluted, every hour during the 



THRUSH. 275 

day for the first" twenty-four hours and subsequently every two hours; 
when improvement occurs the dose may be still further reduced. 
Marked benefit is usually seen in one or two days even in cases that have 
lasted for several weeks. If the case does not yield readily to this treat- 
ment there is probably disease at the roots of the teeth, and when loose 
these should be removed, and the jaw examined to see if there is necro- 
sis. Occasionally when there is no disposition to heal, the shreds of 
necrotic tissue should be carefully removed, and burnt alum or nitrate 
of silver applied. 

The constitutional and dietetic treatment in all these cases should 
be the same as that employed in scurvy — i. e., plenty of fruit, fresh vege- 
tables, and sometimes the internal administration of mineral acids, espe- 
cially aromatic sulphuric acid. Iron is indicated in most of the cases. 

Ulceration of the Hard Palate. — This is usually seen in the first few 
weeks of life, but may occur in any child suffering from marasmus. The 
primary cause may be the injury inflicted in cleansing the mouth. In 
other cases it is due to the friction of the rubber nipple, or some other 
object which the child is allowed to suck. In still others it is appar- 
ently produced by the habit of tongue-sucking frequently observed in 
these young infants. The appearances are quite characteristic : there is 
found, rather far back upon the hard palate, usually in the middle line, 
a superficial ulcer, from a fourth to a half inch in diameter. There are 
no signs of acute inflammation. Thrush may coexist, but it has no rela- 
tion to the production of the disease. Spontaneous recovery usually oc- 
curs in from one to three weeks, provided the cause can be removed. In 
children suffering from marasmus these ulcers are very intractable, and 
in many instances their cure is practically impossible. It is therefore 
especially important to prevent, if possible, their formation by care in 
cleansing the mouth, and in avoiding the other causes referred to. When 
ulcers have appeared they should be treated as in cases of herpetic stoma- 
titis. 

THRUSH. 

{Sprue; German, Soor; French, Muguet.) 

Thrush is a parasitic form of stomatitis characterised by the appear- 
ance upon the mucous membrane, usually of the tongue or of the cheeks, 
of small white flakes or larger patches. It is common in infants of the 
first two or three months, and in all the protracted exhausting diseases 
of early life. 

Etiology. — The exact class to which the vegetable parasite which 
produces thrush belongs has not yet been definitely settled. Robin's 
opinion was long accepted that it was the o'idium albicans; the view of 
Grawitz, that it is the saccharomyces albicans, is now more generally 
adopted. If a little of the exudate from the mouth is placed upon a 



270 



DISEASES OF THE DKJKSTIVE SYSTEM. 



slide and a drop of liquor potassse added, the structure' of the fungus is 
readily seen. With the low power of the microscope there can be made 
out fine threads (the mycelium) and small oval bodies (the spores). 
With a high power the threads can be seen to be made up of a number 

of shorter rods, at the ends of 
which the spore formation 
takes place (Fig. 45). The 
mycelium is produced from 
the spores. The spores of this 
fungus are of very common 
occurrence in the atmosphere. 
It is difficult or impossible 
for thrush to develop upon 
a healthy mucous membrane. 
Its growth is favoured by 
slight abrasions, such as are 
often produced by rough 
methods of cleansing the 
mouth; also by catarrhal sto- 
matitis, a scanty salivary se- 
cretion and want of cleanli- 
The nature of the process which it produces is in all probability a 




Fig. 45. — Thrush Fungus (highly magnified). 
a, mycelium; b, spores; c, epithelial cells 
from the mouth; d, leucocytes; e, detritus, 
(v. Jaksch.) 



ness. 



sugar fermentation, the acid reaction of the mouth being the result of the 
growth rather than its cause. Infection may come from another patient 
by means of a rubber nipple or a cloth which has been used for the 
infected mouth, from the nipple of the nurse, or directly from the air. 
Its production is favoured by a scanty secretion of saliva, hence it is 
frequent in the first two or three months of life; also by an altered 
secretion such as is seen in protracted wasting diseases, entero-colitis, 
marasmus, typhoid, tuberculosis, etc. It is very common in infants suf- 
fering from harelip or any other deformity of the mouth. The disease 
is frequently seen in foundling asylums, in all places where many young 
infants are crowded together, and where cleanliness of mouths, bottles, 
etc., is neglected. 

Lesions. — The spores lodge between the epithelial cells and gradu- 
ally separate the different layers. This occurs before the formation of 
the white pellicle. Later the disease spreads on the surface of the 
mucous membrane, and also penetrates the deeper structures. It may 
invade the blood-vessels and cause thrombosis or even be carried to dis- 
tant parts. Although the saccharomyces albicans is commonly found 
upon flat epithelium, its growth is not confined to it. It usually begins 
at many distinct points upon the mucous membrane, and gradually 
spreads until coalescence takes place; a continuous membrane may be 
thus formed. No pus is produced by the process. 



THRUSH. 277 

The usual seat is the margin of the tongue, the inside of the lips and 
cheeks, and the hard palate, but not infrequently it involves the pillars 
of the fauces, and the pharynx. Further extension in the digestive tract 
than this is rare, although the stomach, and even the intestines, may be 
invaded. I have seen it but once or twice in the oesophagus and never 
in the stomach, and I know of but two reported cases in this country in 
which thrush has been found there. Cases involving the oesophagus and 
the stomach appear from reports to be much more common in Europe. 
In several cases in the Babies' Hospital the saccharomyces albicans has 
been found in the lungs of infants suffering from broncho-pneumonia. 
There are several reported cases of general blood infection from this 
organism. 

Symptoms. — The essential symptoms of thrush are the appearance 
upon the mucous membrane of the mouth — usually beginning upon the 
tongue or the inner surface of the cheek — of small white flakes which 
resemble deposits of coagulated milk, but which differ from them in the 
fact that they can not be wiped off. If forcibly removed, they usually 
leave a number of bleeding points. There may be only a few scattered 
patches, or the mouth and pharynx may be covered. The mouth is gen- 
erally dry, the tongue coated; food may be refused on account of pain, 
and there may be some difficulty in swallowing. The other symptoms 
depend upon the conditions with which the thrush is associated. 

Diagnosis. — This is rarely difficult. The deposit may be mistaken for 
coagulated milk, but is distinguished by the features just mentioned. 
When existing upon the pharynx and fauces it has been confounded with 
diphtheria, although this mistake can hardly be made if all the facts 
of the case are taken into consideration — the age of the patient, the 
involvement of the lips and tongue, the dry mouth, the absence of gland- 
ular enlargement, etc. In any case of doubt the examination of the 
deposit under the microscope at once reveals its true nature. 

Prognosis. — Thrush is not in itself a dangerous disease, except in the 
very rare instances where it may obstruct the oesophagus, and this can 
hardly occur except in a condition of exhaustion which is necessarily 
fatal. In a feeble and delicate infant, or in one with harelip or cleft 
palate, thrush may be a serious complication. With proper treatment 
most of the cases involving only the mouth are readily cured. 

Treatment. — Thrush may usually be prevented by due attention to 
cleanliness of the mouth, rubber nipples, bottles, cloths, etc. In infants 
with deformities of the mouth in institutions, it frequently develops 
despite all precautions. All rubber nipples should be kept in a solution 
of boric acid and the child's mouth should be cleansed several times a 
day. On no account should a feeding-bottle be passed from one child 
to another. 

In the treatment of the disease the essential things are cleanliness, 



278 DISEASES OF THE DIGESTIVE SYSTEM. 

and the use of some mild antiseptic mouth-wash. The best routine treat- 
ment is to cleanse the mouth carefully after every feeding or nursing 
with a solution of bicarbonate of soda, and to apply twice a day a one- 
per-cent solution of formalin. All applications should be carefully made, 
so as not to injure the epithelium. The best method of cleansing is by 
a small swab made with a wooden toothpick and absorbent cotton. Ap- 
plications to be especially avoided are those mixed with honey or any 
syrup. In hospital cases the disease seems to be prolonged by the irrita- 
tion of the rubber nipple of the feeding-bottle. In such it has been 
our practice to feed by gavage for two or three days, as some cases im- 
proved much more rapidly when this was done. 

GONORRHCEAL STOMATITIS. 

There has been described by Dohrn and Rosinski a form of stomatitis 
in the newly born, due to a gonorrhceal infection. This is not likely to 
take place unless the epithelium has been removed. The infection in all 
cases occurred from the mother. The lesion consists in the formation of 
yellowish-white patches upon the tongue or hard palate — regions in 
which the epithelium is liable to be injured by rough attempts at cleans- 
ing the mouth. There may be other evidences of gonorrhceal infection, 
especially ophthalmia. The diagnosis rests upon the discovery of the 
gonococcus in the exudate. In all the cases cited the general health was 
not affected, and recovery followed in the course of a week or ten days. 

The treatment consists in thorough cleanliness and in the application 
of a saturated solution of boric acid, as in thrush. 

SYPHILITIC STOMATITIS. 

The buccal symptoms of hereditary syphilis are important both from 
a diagnostic and a therapeutic standpoint. The most frequent lesions are 
fissures, ulcers, and mucous patches. Fissures are found upon the lips, 
most frequently at the angle of the mouth, and are usually multiple. 
They may be quite deep and cause frequent haemorrhages. Mucous 
patches are superficial ulcers developing from papules which form upon 
the mucous or muco-cutaneous surfaces. In cases of acquired syphilis 
in children the primary sore may be seen upon the tongue, the lip, or the 
tonsil. All these symptoms are more fully considered in the chapter on 
Syphilis. 

DIPHTHERITIC STOMATITIS. 

In severe cases of diphtheria the membrane is found not only upon 
the pharynx and tonsils, but it may appear anywhere upon the buccal 
mucous membrane or the lips. It is questionable whether the diphther- 
itic process ever begins on the mucous membrane of the mouth, or is 



GANGRENOUS STOMATITIS. 279 

ever limited to this part. In my own experience diphtheritic stomatitis 
has always been associated with deposits upon the tonsils and pharynx. 
It is seen only in the severest cases, and in those which, from other con- 
ditions present, are almost necessarily fatal. Bearing in mind the above 
points, it can hardly be mistaken for any other variety of stomatitis, 
although not infrequently the mistake is made of regarding as diph- 
theritic, cases of herpetic stomatitis in which the ulcers have coalesced. 
The treatment, so far as the mouth is concerned, consists in cleanliness 
by frequent gargling or irrigation with a hot saline solution. Forcible 
removal of the membrane is not to be advised. 

GANGRENOUS STOMATITIS— NOMA. 

(Cancrum oris.) 

The term noma is used to designate all forms of spontaneous gan- 
grene occurring in children, which involve mucous membranes or muco- 
cutaneous orifices. The most frequent situation being the mouth, noma 
and gangrenous stomatitis are often used synonymously. Noma may, 
however, affect the nose, external* auditory canal, vulva, prepuce, or anus. 
It is a rare disease, and usually terminates fatally. 

Etiology. — Noma is seldom seen outside of institutions for children, 
where small epidemics are not uncommon. It is usually secondary to 
some of the infectious diseases, most frequently following measles, and 
next to this scarlet fever, typhoid, or whooping-cough. While it may 
occur at any age, most of the cases are in children under five years, and 
in those of poor general condition. Noma seldom attacks parts previ- 
ously healthy. In the mouth it may be preceded by catarrhal, or more 
often by ulcerative stomatitis; in the auditory canal, by a chronic otitis 
media. There seems little doubt that the disease is contagious. In 
1899 I saw five cases in a single ward, all beginning in the auditory 
canal, which were apparently produced by the use of the same syringe 
to clean the ears without proper disinfection. All these children were 
suffering from whooping-cough at the time. 

It is now quite well established that the exciting cause of noma is the 
same as that of ulcerative stomatitis (q. v.). The pathological process 
in one case is of a mild type occurring in patients of considerable 
resistance. In the other it is of a severe or malignant type occurring in 
patients of feeble resistance as a result of previous acute disease. In 
the gangrenous tissue pyogenic cocci and putrefactive bacteria are 
abundant. In the border zone, and extending into the adjacent healthy 
tissue the specific organisms of the disease are found. 

Lesions. — The process is one of slowly spreading gangrene. In most 
of the cases there are thrown out inflammatory products in quite large 
amount, but there is little or no tendency to limitation of the disease. 



2S0 DISEASES OF THE DIGESTIVE SYSTEM. 

This usually advances steadily until death occurs. In a small number of 
cases a line of demarcation finally forms, and the slough separates, leav- 
ing a large area to be partially rilled in by granulation and cicatrisation. 
Other infectious processes are likely to accompany the disease, partic- 
ularly broncho-pneumonia. 

Symptoms. — The constitutional symptoms are not usually severe until 
the local disease has existed for several days. Then those of marked 
prostration and sepsis develop, sometimes quite rapidly. The tempera- 
ture is usually elevated to 102° or 103° F., and sometimes to 104° or 
105° F. There are dulness, apatlry, feeble pulse, muscular relaxation, 
and very often diarrhoea. Before death the temperature may be sub- 
normal. 

Of the local symptoms, often the first to attract attention is the odour 
of the breath; sometimes it is the dusky spot on the cheek or lip. On 
examination of the mouth, there usually is found upon the gum or inside 
of the cheek a dark, greenish-black necrotic mass, surrounded by tissues 
which are swollen and oedematous, so that the cheek or lips may be 
two or three times their normal thickness. Externally the parts are 
tense and brawny from the swelling, this infiltration always extending 
for some distance beyond the gangrenous part. As the process extends, 
the teeth loosen and fall out ; there may be necrosis of the alveolar process 
of the jaw and perforation of one or both cheeks or lower lip. Ex- 
tensive sloughing of the face may take place, usually upon one side, 
sometimes upon both, giving the patient a horrible appearance, as shown 
in Fig. 46. In this patient the process began in the right cheek, subse- 
quently involving the left; perforation occurred in both cheeks, and be- 
fore death a large part of the face was gangrenous. The odour from 
a severe case is very offensive, and, in spite of all efforts at disinfection, 
it may fill the ward or even the house. Pain is rarely severe, and in many 
cases it is absent. Extensive haemorrhages are rare. 

I have notes of seven cases in which, noma affected the ear, being 
preceded by chronic otitis media in every instance. The disease began 
in the deeper structures of the canal, the first symptom noticed usually 
being a nodular swelling just beneath the ear, crowding the lobe upward. 
Shortly afterward there appeared the dirty brown discharge with a gan- 
grenous odour. Later, the gangrenous circle surrounded the meatus, 
which gradually extended, until in some cases the whole side of the face 
and head were involved. A probe could readily be passed into the cra- 
nial cavity. All these cases ended fatally. 

The usual duration of the disease is from five to ten days. If 
recovery takes place, there is first seen a line of demarcation; then the 
slough is thrown off, and granulation and cicatrisation begin, but require 
a long time, usually leaving an unsightly deformity. 

The prognosis is grave, fully three-fourths of the cases proving fatal. 



GANGRENOUS STOMATITIS. 



281 



The results depend not only upon the disease itself, but upon the con- 
dition of the patient with which it is associated. 

Gangrenous stomatitis can hardly be mistaken for any other form of 
disease occurring in the mouth, and early recognition is of great impor- 
tance, since only early treatment is likely to be successful. 




I 



Fig. 46. — Gangrenous Stomatitis, following Measles. 
(From a photograph lent by Dr. Henry Moffat.) 



Treatment. — Much can be clone to prevent the disease by careful 
attention to all the milder forms of stomatitis, particularly to the ulcera- 
tive variety. Frequent and thorough cleansing of the mouth in all acute 
infectious diseases is a part of the treatment which is too often neglected. 
This should be a matter of routine in every severe illness in a young 
child. Recognising the malignant nature of gangrenous stomatitis, its 
treatment should be radical from the very outset. Of the measures 
which have been proposed, that which seems to offer the best chance of 



2S2 DISEASES OF THE DIGESTIVE SYSTEM. 

arresting the process is excision with cauterisation. This should be 
done under anaesthesia. In excising, one should go some distance into 
tissues apparently healthy, for the reason that the process has always 
advanced farther in the subcutaneous tissues than in the skin. The 
edges of the wound should then be thoroughly cauterised, best by the 
Paquelin cautery. Of the other means employed, the use of strong car- 
bolic acid immediately followed by alcohol is probably the best. This is 
to be used after excising or curetting the necrotic tissue. The mouth 
should be kept as clean as possible by the use of peroxide of hydrogen. 
The general treatment should be supporting and stimulating. As the 
possibility of contagion exists, every case should be isolated. 



CHAPTEE II. 

DISEASES OF THE PHARYNX. 
ACUTE PHARYNGITIS. 

Acute pharyngitis may exist as a primary disease, or with any of the 
infectious diseases, particularly scarlet fever, measles, diphtheria, or 
influenza. Secondary pharyngitis will be considered in connection with 
these different diseases. 

Certain children have a constitutional predisposition to attacks of 
acute pharyngitis, and contract it upon the slightest provocation. In 
some of them there is a strongly marked rheumatic diathesis. Attacks 
of acute pharyngitis often follow exposure. In many cases they are 
associated with acute disturbances of digestion. All of the above causes 
probably act by producing local and general conditions favourable to 
the development of micro-organisms already present in the mouth. The 
bacteria most frequently associated with severe attacks are the staphylo- 
coccus, the pneumococcus, the streptococcus, and less frequently, the 
bacillus influenzas. 

In acute catarrhal pharyngitis the inflammation may involve the en- 
tire mucous membrane of the tonsils, fauces, uvula, posterior and lateral, 
pharyngeal walls, or any part of it. It may exist alone, or in connection 
with a similar inflammation in the rhino-pharynx or in the lar} T nx. In 
the beginning there is seen an acute redness, usually involving the entire 
pharynx. This may entirely subside after twenty-four hours, or it may 
be followed by the usual changes of acute catarrhal inflammation — 
dryness, swelling, and oedema. Later there is increased secretion of 
mucus, and finally there may be muco-pus. Occasionally slight haemor- 
rhages are present. 

There is pain at the angle of the jaws, which is increased by swallow- 



UVULITIS. 283 

ing, also a sensation of dryness and roughness in the pharynx, and often 
an irritating cough. There may be slight swelling of the neighbouring 
lymphatic glands. The constitutional symptoms in young children are 
often severe. Not infrequently there is a sudden onset with vomiting, 
and a rise of temperature to 102° or even 104° F. These symptoms are 
usually of short duration, frequently less than twenty-four hours, and in 
two or three days the patient may be entirely well. In other cases the 
pharyngitis may be accompanied or followed by laryngitis. 

Acute primary pharyngitis is to be distinguished from scarlet fever, 
diphtheria, measles, and influenza. A positive diagnosis from scarlet 
fever is impossible until a sufficient time has elapsed for the eruption to 
appear, and the patient should be closely watched for the first sign of 
this. If scarlet fever is prevalent, a child with the sjonptoms of severe 
pharyngitis should at once be isolated while waiting for the diagnosis 
to be settled. There is commonly less difficulty in excluding measles 
because of the absence of Koplik's sign on the buccal mucous membrane, 
and of the accompanying catarrh of the eyes and nose. Catarrhal diph- 
theria can be excluded only by culture. 

The first step in the treatment of acute pharyngitis is to open the 
bowels freely by means of calomel, castor oil, or magnesia. The child 
should be kept in bed, and the diet should be fluid, or, in the case of 
infants, the amount of food should be much reduced. Pieces of ice may 
be swallowed frequently for the relief of pain and thirst. Internally 
there may be given two grains of phenacetine every four hours to a child 
of three years. It is important at the outset to induce free perspira- 
tion. The disease is not serious, and the indications are to make the 
child as comfortable as possible during the short attack. I have seen 
but little benefit from the use of aconite, although for years I saw it 
used as a routine treatment. 



UVULITIS. 

Acute inflammation of the uvula, with swelling and oedema, occurs 
as a part of the lesion in acute pharyngitis. In rare instances the uvula 
may be the principal or the only seat of inflammation. Huber (New 
York) has reported two cases, one of which is unique. An infant ten 
months old was apparently well until two hours before it was seen, when 
there was noticed a constant irritating cough, accompanied by consider- 
able gagging. Later there could be seen in the mouth a prominent red 
mass, the enlarged and elongated uvula. It was accompanied by par- 
oxysms of coughing, which interfered both with nursing and deglutition. 
The general symptoms were quite alarming. The uvula was found to be 
fully one inch long and half an inch wide, red and cedematous ; in other 
respects the throat was normal. The symptoms were relieved by multiple 



284 DISEASES OF THE DIGESTIVE SYSTEM. 

noodle punctures and the use of ice. In such conditions the greatest 
relief is often afforded by the application of adrenalin, or its use as a 
spray or gargle. 

ELONGATED UVULA. 

Probably this is primarily a congenital condition. It is increased by 
repeated attacks of acute or subacute inflammation. The degree of 
elongation varies in different cases; in some it may reach an inch in 
length. Only the mucous membrane is involved in the elongation. The 
symptoms are those of local irritation, especially a cough upon lying 
down, and the sensation of a foreign body in the pharynx. In some 
cases it may be a reflex cause of asthma, or, more frequently, of catar- 
rhal spasm of the larynx. The diagnosis is very easily made by in- 
specting the throat. The treatment consists in grasping the tip of the 
uvula with forceps and cutting off the excess with the scissors, or a 
uvulatome. Care should be taken not to cut off too much of the uvula, 
or severe haemorrhage may occur. 

RETRO-PHARYNGEAL ABSCESS. 

Two distinct varieties are seen: (1) The so-called idiopathic abscesses 
which belong to infancy, and (2) abscesses secondary to caries of the 
cervical vertebrae. 

Retro-pharyngeal Abscess of Infancy. — All of the later investigations 
regarding this disease go to show that primarily it is not a cellulitis, 
but a suppurative inflammation of the lymph nodes (lymphatic glands) 
with a surrounding cellulitis. The retro-pharyngeal lymph nodes form a 
chain on either side of the median line between the pharyngeal and the 
prevertebral muscles. These nodes are said to undergo atrophy after 
the third year, and in some cases to disappear entirely. Retro-pharyngeal 
abscess — or, more properly, retro-pharyngeal lymphadenitis, since the 
process does not invariably go on to suppuration — is probably never 
primary, but secondary to infectious catarrhs of the pharynx, and is set 
up by the entrance of pyogenic bacteria, usually the staplvylococcus or 
streptococcus. Its pathology is the same as the more frequent sup- 
purative inflammation of the external cervical lymph nodes, with which 
it is sometimes associated. Usually only a single node is involved, but 
sometimes two or three are affected, and these may be situated upon 
opposite sides. I have frequently seen retro-pharyngeal lymphadenitis 
so severe as to give rise to marked local symptoms, although it did not 
go on to suppuration. Kormann's observations, however, show that 
swelling of these glands in diseases of the mouth and throat is very 
much more common than is generally supposed. Similar abscesses from 
suppurative inflammation of other lymph nodes in the neighbourhood 



RETRO-PHARYNGEAL ABSCESS. 285 

of the pharynx may occur. I have seen one situated between the epiglot- 
tis and the base of the tongue. 

Etiology. — These cases almost invariably occur in infancy. Fully 
three-fourths of those that have come under my observation have been in 
patients under one year. Bokai (Buda-Pesth) reports that of sixty cases 
observed, forty-two occurred during the first year, eleven during the 
second }'ear, and only seven at a later period. The primary disease is 
usually a severe rhino-pharyngitis, or an attack of epidemic influenza, 
but rarely it occurs as a sequel of scarlet fever or measles. In six hun- 
dred and sixty-four cases of scarlet fever, Bokai noted retro-pharyngeal 
abscess in seven cases. After measles it is even more rare. Retro- 
pharyngeal abscess usually occurs in winter or spring, on account of the 
prevalence of the diseases upon which it depends. It is seen in children 
previously robust, but more often in those who are delicate and who in 
consequence are prone to severe catarrhal affections. 

Symptoms. — The early symptoms in most cases are merely those of 
an ordinary rhino-pharyngeal catarrh. After this has subsided the tem- 
perature may remain slightly elevated, often for a week or more, before 
local symptoms are noticeable. Sometimes, without any distinct history 
of previous catarrh, there are seen quite high temperature, from 102° to 
104° F., loss of flesh, and prostration. A careful examination may be 
required, and sometimes observation for a day or two, before the ex- 
planation of these constitutional symptoms is discovered. In other cases 
the early constitutional symptoms are so slight as to escape notice, and 
the local symptoms are the only ones present. Although usually these 
are not severe, retro-pharyngeal abscess may cause dyspnoea, which in a 
short time assumes an alarming character. The duration of the inflam- 
matory process before abscess forms is generally five or six days, but it 
may be several weeks. The temperature is invariably elevated, usually 
from 100° to 103° F. ; occasionally it may be 104° or 105° F., with 
symptoms of prostration seemingly out of all proportion to the local 
disease, but which are to be explained by the tender age and feeble re- 
sistance of the patient. 

The most characteristic local symptoms are the posture, the head 
being drawn far backward to relieve pressure on the larynx, the noisy 
respiration with the mouth open, and difficulty in deglutition. Some- 
times the first thing to attract notice is a sudden attack of dyspnoea 
severe enough to cause asphyxia. This is due to the pressure forward 
of the abscess encroaching upon the larynx. The mouth may be dry, or 
there may be a copious secretion of pharyngeal mucus. The dyspnoea 
is in most cases greater on inspiration, and in some it is noticed only 
then, expiration being normal. The difficulty in swallowing is greater 
when the tumour is low. The child may find it impossible to swallow, 
and in consequence may refuse to nurse; or the difficulty in nursing 



286 DISEASES OF THE DIGESTIVE SYSTEM. 

may depend upon the nasal obstruction. Sometimes there is regurgita- 
tion of food through the nose or mouth. The voice is usually nasal. 
Generally there is no hoarseness, but a peculiar short cry which is quite 
characteristic. There may be, although rarely, aphonia. Usually there 
is some swelling to be seen externally, just below the angle of the jaw 
in front of the sterno-mastoid muscle; exceptionally this may be more 
prominent than the internal swelling. In one or two cases I have no- 
ticed torticollis as an early symptom. 

A positive diagnosis is made by an examination of the throat. On 
inspection there is seen a distinct bulging of the lateral wall of the 
pharynx, usually a little above the base of the tongue. The swelling may 
be so great as to crowd the uvula to one side and nearly fill the pharynx. 
It is rarely if ever in the median line. There is usually redness of the 
mucous membrane and oedema of the uvula and of the adjacent parts. 
On digital examination the swelling is made out even better than by in- 
spection. It may be situated so low down as not to be visible at all. 
In the early stage there may be felt only a localised induration or 
a somewhat diffuse swelling, but by the time the swelling is large 
enough to produce marked symptoms, fluctuation can generally be dis- 
covered. 

Prognosis. — When left to itself the abscess may open into the pharynx, 
the pus being swallowed or expectorated. The cavity may close rapidly 
by granulation, and in a few days the patient be entirely well; or the 
abscess may refill. External opening I have never known to take place. 
It is rare for much burrowing to occur. In young or very delicate in- 
fants the constitutional symptoms may be so severe that the child con- 
tinues to fail even after the evacuation of the abscess, and dies usually 
from broncho-pneumonia. 

Death may occur from asphyxia due to pressure upon the larynx, 
to oedema of the glottis, or from rupture of the abscess into the air 
passages, especially if this occurs during sleep. Carmichael, Bokai, and 
others have reported deaths from ulceration into the carotid artery, or 
one of its large branches. Carmichael's patient was only five weeks old. 
The general mortality is from five to ten per cent; many deaths are 
due to a failure to make the diagnosis. Gautier has collected ninety- 
five cases, with forty-one deaths. In my experience death has most fre- 
quently resulted from late broncho-pneumonia; in one case it was due to 
a secondary retro-oesophageal abscess. 

Diagnosis. — Retro-pharyngeal abscess is to be suspected if in an in- 
fant there is difficulty in swallowing, noisy dyspnoea, mouth-breathing, 
and the head drawn backward. A positive diagnosis is possible only by 
a digital examination of the pharynx. The mistake most often made 
is, that the physician, called to a young child suffering from great 
dyspnoea, has jumped at a diagnosis of laryngeal stenosis, and forth- 



RETRO-PHARYNGEAL ABSCESS. 287 

with performed tracheotomy or intubation, without taking the trouble 
to get the history or to make a careful examination of the pharynx. 
Many such cases are reported in which the child has died during the 
operation or immediately afterward, the autopsy first revealing the 
nature of the disease. A sudden attack of dyspnoea like that caused 
by the rupture of an abscess might be produced by the lodgment of a 
foreign body in the pharynx or larynx. A digital examination would aid 
in the diagnosis. I once saw in an infant a sarcoma of the pharyn- 
geal lymph glands which gave an external and internal tumour exactly 
like that of a retro-pharyngeal abscess. 

Treatment. — Before the abscess has pointed, hot applications may be 
made to the throat to relieve the symptoms and to hasten the formation 
of pus, since resolution is not to be expected. Spontaneous opening 
should never be waited for, on account of the danger of the rapid devel- 
opment of serious symptoms from pressure or oedema, or of suffocation 
from an opening into the air passages, especially during sleep. 

As soon as the diagnosis is made the case should be carefulty watched, 
and as soon as a point of superficial fluctuation is detected, but not before, 
the pus should be evacuated. External incision has its advocates, but 
the internal opening is, to my mind, much to be preferred. In opening 
through the mouth the patient should be seated in an upright position 
and the head firmly held. The use of a mouth-gag may cause asphyxia. 
With the finger as a guide, a bistoury, which has been guarded to its 
point, is introduced and the abscess opened at its thinnest portion, the 
incision being made toward the median line. The head should then be 
bent forward, to allow the pus to escape through the mouth. It is well 
to insert the finger into the cavity to enlarge the opening and break 
down any septa; for after a simple puncture the abscess may refill. In- 
cision, although usually easy, in some cases may be quite difficult on 
account of the swelling and the small pharynx of the infant. For the 
past few years I have adopted the plan of opening these abscesses with 
the finger nail, sharpened to a point, a procedure simple, efficient, and 
free from danger. I have seldom seen a case in which this was difficult. 
The amount of pus evacuated is from one drachm to half an ounce. In 
the majority of cases no after-treatment is required. The relief of the 
dyspnoea and dysphagia is immediate, and, except in young infants, 
recovery usually rapid. 

Retro-pharyngeal Abscess from Pott's Disease. — This form is rare in 
comparison with that just described, and under three years of age it is 
extremely so. These abscesses are usually larger, and the amount of 
pus contained may be from four to eight ounces. They form very much 
more slowly, often lasting for months, and as with other secondary 
abscesses, the constitutional symptoms are seldom severe. The swelling 
is frequently in the median line, and is not so circumscribed as in the 



288 DISEASES OF THE DIGESTIVE SYSTEM. 

idiopathic cases. The pus often burrows along the spine for several 
inches. 

The symptoms of Pott's disease of the cervical region are usually 
present for several months before the appearance of the abscess. Some^ 
times the abscess precedes the deformity, and it may be the first intima- 
tion of the existence of bone disease. The local symptoms resemble 
those of the idiopathic cases, but they develop more slowly, and sudden 
attacks of fatal asphyxia are very rare. External swelling is usually 
seen, and it may be quite large, extending almost from one ear to the 
other, forming a distinct collar. On digital exploration there may be 
found an irregularity of the anterior surface of the cervical vertebrae, 
and occasionally a marked angular prominence. 

When left to themselves these abscesses may open externally in front 
of the sterno-mastoid muscle just below the jaw, sometimes nearly as low 
as the clavicle; they may rupture internally into the pharynx, the 
oesophagu-, cr the air passages; or they may burrow a long distance in 
front of the spine. Death may result from pressure upon the larynx, 
or from rupture into the larynx, trachea, or pleura; all these, however, 
are rare. The abscesses not infrequently refill after they are evacuated, 
and occasionally a discharging sinus is left for many months. 

Treatment. — These abscesses should be opened as soon as they are 
large enough to give rise to local symptoms. The external incision just 
in front of the sterno-mastoid muscle is generally to be preferred to 
opening through the mouth, since it gives better drainage, and the after- 
treatment is more easily carried on; and a sinus opening externally is 
less objectionable than one opening into the pharynx. 

ADENOID VEGETATIONS OF THE VAULT OF THE PHARYNX. 

This is a very common condition and one much neglected by the 
general practitioner. It is the source of more discomfort and the origin 
of more minor ailments than almost any other pathological condition of 
childhood. 

There is a mass of lymphoid tissue situated at the vault of the 
pharynx which in structure closely resembles the tonsils. It is often 
spoken of as the " pharyngeal tonsil/' Like the f aucial tonsils, this may 
become greatly hypertrophied, so as to form a tumour large enough to 
fill the rhino-pharynx completely. These tumours have a broad attach- 
ment which is sometimes more to the roof, and sometimes more to the 
posterior wall of the pharynx. The term adenoid vegetations was given 
to them by Meyer, who first described them in 1868. In infancy these 
growths are soft, vascular, and spongy; in older children they become 
firm, dense, and more fibrous. Their appearance is well shown in Fig. 
47. Adenoid vegetations are associated with hypertrophy of the faucial 



ADENOID VEGETATIONS OF THE PHARYNX. 289 

tonsils in about one-third of the cases. Growths large enough to cause 
decided nasal obstruction may in time produce changes in the facial 
bones amounting to positive deformity. The bony palate may be dome- 
shaped or even acutely arched; the dental arch of the upper jaw be- 




Fig. 47. — Adenoid Vegetations, Natural Size. (1) From child eight months old; 
(2) from child twenty-two months old ; (3) from child two and one-half years old ; (4) 
from child two and one-half years old; (5) from child three years old. With the ex- 
ception of (5) all were removed with a single sweep of the curette. Although the 
growths represented are somewhat larger than the average for the ages mentioned, 
just such ones are constantly met with in practice. 

comes almost V-shaped. Deformities of the thorax also occur, which 
will be described with the symptoms. 

Etiology. — Hereditary influences certainly play some part in the 
production of this condition. I have frequently known every one of a 
large family of children to be affected, and often the parents have suf- 
fered from the same condition. In many cases adenoid growths are con- 
genital. Rachitic children are somewhat oftener affected than others, 
but no connection with syphilis has been traced. Much interest has 
lately been awakened regarding the relation of adenoid growths to tuber- 
culosis. Of 945 cases collected by Lewin in which specimens of adenoids 
were examined, tuberculosis was present in five per cent. Though this 
proportion is no doubt much higher than will be found in private prac- 
tice, the fact is an important one; for it is highly probable that this is 
the channel of infection in not a few cases of tuberculosis. Adenoids 
20 



290 DISEASES OF THE DIGESTIVE SYSTEM. 

are most common in damp, changeable climates. Their first symptoms 
often follow an attack of measles, scarlet fever, or diphtheria. The re- 
peated head colds are more often a result than a cause of the condition. 

Symptoms. — The symptoms of adenoid growths are usually first no- 
ticed when children are from eighteen months to three years old; but 
they may be present almost from birth. I have in several instances seen 
them to a marked degree in infants only a few months old. The symp- 
toms generally increase in severity as age advances, being always better 
in summer and worse in winter, until the age of six or seven is reached. 
The chief symptoms are those which relate to (1) chronic rhino-pharyn- 
geal catarrh, (2) mechanical obstruction, (3) otitis and other aural 
conditions, (4) general malnutrition and anaemia, (5) reflex nervous 
phenomena. 

The rhino-pharyngeal catarrh shows itself by a persistent nasal dis- 
charge, frequently recurring acute attacks, or head colds, during the 
entire winter season. In susceptible children these attacks are often the 
beginning of a bronchitis, which may keep a young child indoors almost 
the entire winter. 

The obstructive symptoms are inability to blow the nose, mouth- 
breathing constantly or only during sleep, and a nasal voice. The 
difficulty in breathing is increased when the child lies upon the back. 
In consequence of this, children sleep in all sorts of positions — lying 
upon the face, sometimes upon the hands and knees, and often toss 
restlessly about the e crib in the vain endeavour to find some position in 
which respiration is easy. The attacks of dyspnoea at night may amount 
almost to asphyxia, and are the explanation of many of the so-called 
night-terrors from which children suffer. When the obstruction has 
existed from infancy there are often deformities of the chest; these are 
most marked in rachitic subjects. The most frequent one consists in 
deep lateral depressions of the lower part of the chest, with a promi- 
nence of the sternum. The deformity is due to interference with pul- 
monary expansion. 

There is often seen a flattening at the root of the nose, and some- 
times a prominence of the transverse vein in this region. 

Some impairment of hearing exists in a large proportion of the cases. 
Blake (Boston) found this to be true in 39 out of 47 cases examined; 
in 35 of these marked improvement in the hearing followed removal 
of the adenoid growths. Deafness may be due to tubal catarrh or to 
otitis. Often a history is given of several attacks of suppurative otitis. 

The reflex symptoms associated with adenoid growths are many. 
One of the most important is catarrhal spasm of the larynx, or the famil- 
iar spasmodic croup. In my experience the majority of young children 
who are subject to such attacks have adenoids, the removal of which 
is frequently followed by their complete cessation. Other respiratory 



ADENOID VEGETATIONS OF THE PHARYNX. 291 

symptoms associated with adenoids are intractable coughs, frequently 
of a spasmodic character, without bronchial symptoms or signs, and per- 
sistent hoarseness, lasting for months or even years, and recurring every 
cold season. Both these conditions are often cured by the removal of 
the adenoids after all other treatment has been without effect. To these 
growths bronchial asthma also is very frequently due. Their relation to 
incontinence of urine is often an intimate one ; the two coexist in a large 
number of patients, and in a certain number removal of the adenoids 
cures the incontinence. Headaches are very common; stammering may 
be present ; chorea and even epileptiform seizures have been attributed to 
adenoids, although I have never seen either. 

The general health of patients suffering from adenoids may be im- 
paired from lack of oxygen due to obstructed respiration, from loss of 
sleep, and from confinement to the house, necessitated by attacks of 
bronchitis or head colds. Marked anaemia is often present. In old and 
neglected cases of a severe character, children may be stunted in growth, 
and their facial expression dull and stupid. They are languid, listless, 
often depressed, and this with their deafness frequently causes them to 
be regarded in school as children who are somewhat deficient mentally. 

These patients are always better in summer and worse in winter. 
The natural course of the growths if left to themselves is to increase up 
to a certain point, and then to remain stationary until puberty, when 
they usually undergo atrophy. This, with the marked increase in the 
capacity of the rhino-pharynx which occurs at this time, results in a dis- 
appearance of the most aggravated symptoms. The removal of the pa- 
tient to an elevated region with a dry atmosphere will often result in a 
relief from all the symptoms, and a diminution in the size of the growth, 
but unless such a change in residence is permanent the symptoms are 
liable to return. Under ordinary circumstances there is little or no 
tendency to spontaneous recovery. In children with adenoid growths 
attacks of diphtheria, scarlet fever, measles, and whooping-cough are all 
likely to be more severe. 

Diagnosis. — In a well-marked case the condition is usually evident 
from the history, and can scarcely be overlooked. The intractable nasal 
catarrh, upon which no treatment, local or general, has more than a tem- 
porary influence, the mouth-breathing, the disturbed sleep, and the 
slight deafness — all are characteristic. In some even of the marked 
cases, attention may be drawn to the larynx, bronchi, or ears as the seat 
of disease. At other times the patients come for treatment on account 
of the general symptoms — the nervous depression, the headaches, or the 
anaemia. In rare cases the leading symptom may be epistaxis. The 
symptoms do not always depend upon the size of the growth, for in a 
small throat quite a small growth may cause very marked symptoms. 

Although the history is in most cases clear, only an examination can 



292 DISEASES OF THE DIGESTIVE SYSTEM. 

make us certain that an adenoid growth exists. The best method of ex- 
amination consists in a digital exploration of the pharynx; but this 
requires a little practice before it is very satisfactory. The head is stead- 
ied by one hand, and the forefinger of the other is passed up behind the 
soft palate. The growth is ordinarily felt as an irregular, granular, soft, 
velvety mass, or sometimes as a firm tumour completely blocking the 
passage : and the finger, when withdrawn, is almost invariably covered 
with blood. By posterior rhinoscopy, the growth in older children can 
often be seen. 

Treatment. — The disappearance of adenoid growths is possible only 
when they are small. This is aided by removal to a warm, dry climate 
for the winter season. All possible means should be employed to prevent 
these patients from taking cold, such as proper clothing, cold sponging, 
cod-liver oil, etc. With the larger growths these methods may improve 
the catarrhal symptoms, but can hardly affect the obstructive ones. The 
reduction of tumours of any considerable size by local applications is, I 
think, a delusion; every marked case that has come to my notice has 
been relieved only by operation. 

Eemoval of adenoid growths is indicated: (1) "When the obstructive 
symptoms — habitual mouth-breathing, disturbed sleep, nasal voice, chest 
deformities, etc. — are marked; (2) for a chronic nasal discharge, con- 
stantly recurring head colds, particularly when these tend to attacks 
of bronchitis or laryngitis; (3) where there is asthma or repeated at- 
tacks of catarrhal spasm of the larynx; (4) with deafness, chronic otitis, 
or repeated attacks of acute otitis; (5) for certain nervous symptoms — 
enuresis, stammering, chorea, headaches, night-terrors, etc. Although 
striking improvement is not infrequent, one should be cautious about 
promising too much from operation, especially as regards the nervous 
conditions; also in older children when there is deafness or asthma. 

The preferable time for operation is the late spring or early summer, 
in order that during the warm months the mucous membranes may have 
an opportunity to regain their normal condition; however, operation 
may be done at any time except during attacks of acute catarrh. Unless 
the symptoms are very marked, I prefer to defer operation until a child 
is at least two years old. 

Eemoval of adenoids by scraping with the finger nail is at best a very 
uncertain method, and is not to be advised, except in the case of chil- 
dren under two or two and a half years old, where the growths are gen- 
erally small and the patients easily handled. The operation is preferably 
done with general anaesthesia : first, for the sake of thoroughness : sec- 
ondly, to avoid the fright and pain which so bloody an operation is apt to 
cause in those who are older, and especially in very nervous children. So 
many deaths from operations for adenoids or tonsils under chloroform 
have now been reported, and so many narrow escapes have occurred that 



ADENOID VEGETATIONS OF THE PHARYNX. 293 

have not been reported, that chloroform anaesthesia should, I think, be 
given up altogether. My preference is for ether; in older children it may 
with advantage be preceded by nitrous oxide, and sometimes with such 
patients the nitrous oxide alone may be used ; but this is not to be advised 
with very young children. Deep anaesthesia is not usually necessary, and 
if the semi-erect position is assumed it increases the danger of the 
entrance of blood or portions of the growth into the larynx, which might 
cause asphyxia. 

The only instruments required are a mouth-gag, like that used for 
intubation, and modified Gottstein's curettes, which should be sharp. 
The physician should have several sizes with different curves to suit the 
size and attachment of the growth and the capacity of the throat. Many 
of the instruments used for young children are too large, the smaller 
ones being more easily manipulated and less liable to do harm. 

During operation it is an advantage to have the patient raised to a 
little more than a half-reclining posture and the head firmly steadied. 
Many of the growths encountered in ordinary practice, such as Nos. 1, 
2, and 3 in the illustration, can be removed with one sweep of the curette, 
the mass usually coming away in a single piece. Others may require 
the instrument to be used two or three times. The forceps (Lo wen- 
berg's and various modifications) in unskilled hands are capable of doing 
much harm. One unfamiliar with their use may easily tear away pieces 
of the uvula, soft palate, pharyngeal wall, and even portions of the 
Eustachian tubes. 

Haemorrhage is always abundant, and seems alarming to one who sees 
it for the first time. In an average case it amounts to one or two ounces, 
but generally ceases in a few minutes. A child should not pass from 
the physician's observation until all bleeding has stopped. He should 
be kept quiet, preferably in bed, for twenty-four hours ; and in the house 
for five or six days, unless the weather is warm. No after-treatment is 
necessary. Recurrences are occasionally seen even after a thorough 
operation by an experienced person. But many of them are due to the 
fact that the primary operation was incomplete. The improvement gen- 
erally begins in a few days, sometimes at once, though the full benefit 
may not be seen for a month. The breathing becomes freer, the sleep 
more quiet ; the mouth may soon be habitually closed ; voice and hearing 
improve, and the benefit to the general health is soon apparent. The 
pallor, listlessness, and inattention disappear, and a rapid increase in 
weight often follows. The entire appearance of the child may in a few 
months be transformed. 

Dangers and Accidents from Operation. — While it is rare that any 
accidents of a serious nature are met with, it should not be forgotten 
that they may occur. Undue laceration of the parts may result from a 
bungling operation, particularly with too large curettes or with the for- 



294 DISEASES OF THE DIGESTIVE SYSTEM. 

ceps. Haemorrhage may be excessive or even fatal. I have seen but one 
case of fatal haemorrhage, this in a bleeder, and but one other instance of 
serious haemorrhage. A fatal result is exceedingly rare. Haemorrhage 
may be continuous after operation, or secondary, in which case it almost 
invariably occurs within twent}'-four hours. It is important, therefore, 
that the patient be kept under observation for that time. Bleeding 
is best controlled by injecting into the rhino-pharynx through the 
nostrils one or two drachms of hydrogen peroxide, full strength, or, 
this failing, a solution of adrenalin (1-1000) may be used in the same 
manner. As a last resource plugging of the rhino-pharynx and posterior 
nares may be resorted to. In all cases the patient should be kept abso- 
lutely quiet. 

Occasionally an acute attack of bronchitis or otitis occurs after oper- 
ation; and in a few recorded instances acute meningitis has followed. 
The danger of asphyxia from the entrance of blood or the tumour into 
the larynx has already been mentioned. 

The danger from chloroform anaesthesia is due not so much to the 
nature of the operation as to the condition of the patient. It is now 
well established that all children in whom the condition known as status 
lymphaticus is present, bear chloroform very badly. 



CHAPTER III. 

DISEASES OF THE TONSILS. 

The tonsils are lymphoid structures closely resembling Peyer's 
patches, but, instead of having a flattened surface, the lymphoid tissue in 
the tonsil is folded upon itself, forming quite deep depressions — the ton- 
sillar crypts. These crypts, like the surface of the tonsils, are lined by 
epithelial cells. They contain lymphoid cells, desquamated epithelium, 
particles of food, and bacteria. Under normal conditions the tonsils 
take no part in absorption from the mouth. When, however, their epi- 
thelium is diseased or removed, the tonsils absorb with very great facil- 
ity every sort of poison which the mouth may contain. Such poisons are 
taken up by the lymphatics, and through them reach the general circu- 
lation. 

Acute inflammation of the tonsils, like that of the pharynx, occurs 
regularly in diphtheria, scarlet fever, and measles, less frequently in the 
other infectious diseases. The secondary forms will be considered with 
the diseases with which they are associated. 

Acute catarrhal tonsillitis, or inflammation of the mucous membrane 
covering the tonsils, occurs as part of the lesion in acute pharyngitis, 
but very rarely is seen alone. 



MEMBRANOUS TONSILLITIS. 295 

MEMBRANOUS TONSILLITIS. 

(Pseudo-diphtheria; Streptococcus Angina; Croupous Tonsillitis.) 

This occurs both as a primary inflammation and secondary to the 
acute infectious diseases, especially scarlet fever and measles. The an- 
gina of scarlet fever is essentially a part of that disease and is more 
fully considered in connection with it. 

Etiology. — As was first shown by Prudden in 1888, and abundantly 
confirmed by others since that time, this inflammation is usually due to 
the streptococcus; it may be found alone, or associated with the staphy- 
lococcus aureus, and occasionally the staphylococcus may be found alone. 

The streptococcus is very frequently found in the throats of healthy 
children, particularly in winter and in cities, and more often in those 
who live in tenements or who are inmates of hospitals or other institu- 
tions. The local conditions in the mucous membranes during an attack 
of measles, scarlet fever, and other infectious diseases, are especially 
favourable for the development of these germs, which at such times are 
very offen present in great numbers even when no membrane is seen. 

Lesions. — In the primary cases the membrane is generally confined 
to the tonsils or is chiefly there, only small deposits appearing elsewhere. 
In the secondary cases, the entire pharynx may be covered and the dis- 
ease may extend to the nose, the mouth, the middle ear, and rarely to the 
larynx, trachea, and bronchi. 

The structure of the membrane resembles that of true diphtheria, 
and it may be impossible by a microscopical examination to separate the 
two diseases. 

In the mild cases the inflammation of the mucous membrane is a 
superficial one and the pseudo-membrane is not very adherent. In the 
severe cases, chiefly the secondary ones, the process extends much deeper. 
Besides the pseudo-membrane upon the surface, there is intense con- 
gestion, oedema, and cell-infiltration of all the lymphoid and cellular 
tissue of the pharynx. It may involve the tonsils, soft palate, uvula, epi- 
glottis, adenoid tissue of the vault and the entire pharyngeal ring, and 
also extend to the external lymph nodes and surrounding cellular tissue. 
The process both in the throat and externally in the neck may terminate 
in resolution, suppuration, or in necrosis. 

The streptococci are found in the false membrane, in the underlying 
mucous membrane, in the lymph spaces and in the lymph nodes. In the 
most severe cases there are present the lesions of a general streptococcus 
infection. 

Symptoms. — 1. The Primary Cases. — The onset is usually abrupt, 
with well-marked symptoms : there are frequently chilly sensations, head- 
ache, vomiting, general pains, and in most cases the child complains of 
soreness of the throat and pain on swallowing. There are first seen a 



296 DISEASES OF THE DIGESTIVE SYSTEM. 

general redness and swelling of the tonsils, sometimes of the entire 
pharynx ; shortly afterward membranous patches appear upon the ton- 
sils. These vary greatly in appearance. In colour they are yellow or 
gray, often changing later to a dirty olive tint. (Plate XVIII, c.) The 
membrane seems loosely attached and can frequently be wiped off with a 
swab. It is often irregular in its outline, which is not sharply defined. 
The membrane usually remains but three or four days and disappears 
rapidly. As a rule, it is limited to the tonsils, and does not spread after 
it first forms. Occasionally, however, small patches are also seen upon 
the fauces or the pharynx. The constitutional symptoms are generally 
severe during the first two days, and the temperature may be 103° or 
10-1° F., but by the third day it falls, and most of the symptoms subside. 
It is rare for the disease to extend either to the nose or the larynx. Gen- 
erally there are no complications and no sequelae. 

2. The Secondary Cases. — Some of these are mild, and do not differ 
from those just described, but most of the severe cases are included in 
this group. The clinical picture of the latter is that of scarlatina angi- 
nosa, as given by the older writers. 

In measles the throat symptoms are somewhat later than in scarlet 
fever; they may begin at the height of the primary fever, and increase 
while the eruption fades. The process is almost invariably complicated 
by broncho-pneumonia. 

Secondary cases as a class are characterised by high temperature 
(Fig. 48), rapid, feeble pulse, great prostration, delirium, apathy or 
stupor, and often albuminuria. In fatal cases death usually occurs 
at the height of the disease, from asthenia, broncho-pneumonia, or 
nephritis. If none of these complications develop, patients may with- 
stand the toxic symptoms even when they are very severe. 

There may be in connection with the local process in the throat, deep 
sloughing of the tonsils or adjacent structures, suppuration of the lym- 
phatic glands or in the cellular tissue of the neck, occasionally followed 
by serious haemorrhage. However, these complications are rare, and if 
the patient survives the danger of the acute stage of the disease, he 
usually recovers. 

Diagnosis. — The clinical features which distinguish membranous ton- 
sillitis from diphtheria are considered under the latter disease. It is 
impossible in any case to be certain of the diagnosis except by cultures; 
for, although by clinical symptoms alone one may in the great majority 
of cases be certain that a given case is one of true diphtheria, to say 
that any membranous inflammation of the throat is not diphtheria is 
impossible. The bacteriologists have taught us to be cautious in pro- 
nouncing too positively even upon mild cases, as it has been shown 
that some of them may be caused by most virulent diphtheria bacilli. 

A membrane which appears in the throat early in the course of 



MEMBRANOUS TONSILLITIS. 



297 



measles or scarlet fever, or at the height of the primary disease, is usu- 
ally due to the streptococcus; while one which develops late or after the 
primary fever has subsided, is frequently due to the diphtheria bacillus. 



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Fig. 48. — Streptococcus Angina, following Measles. The chart begins at the time 
of the full eruption in a severe case of measles. On the third day the temperature 
fell, with fading eruption, and child seemed convalescent. With secondary rise in 
temperature, the tonsils, which before had been only red, showed membranous 
patches, the exudation rapidly spreading until the entire pharynx was covered; 
throat symptoms very severe, with great swelling of cervical glands, but the mem- 
brane did not extend beyond the pharynx. From sixth to twelfth day a most pro- 
found septicaemia, so that life was despaired of. The patient was a vigorous child, 
and, escaping both nephritis and pneumonia, made a good recovery. Convalescence 
quite rapid; no sequelae. Repeated cultures were made from the throat, but all 
showed only streptococci. Patient a girl four years old. Case observed in private 
practice. 



Prognosis. — In a child previously healthy, primary membranous ton- 
sillitis is not a serious disease. In the secondary cases, we find very dif- 
ferent conditions. From the best available statistics it would appear 
that the usual mortality, when it is secondary to scarlet fever and 
measles, is from fifteen to twenty per cent. However, when these dis- 
eases prevail epidemically in institutions, the mortality is often higher 
than this. 

Treatment. — Every child with a membranous patch on the tonsils 
requires close watching; strict quarantine should be enforced until the 
diagnosis is positively settled. If under three years old, unless the case 
can be seen frequently, diphtheria antitoxin should be administered, 
pending the result of a bacteriological examination. The primary cases 
require only the treatment of an attack of tonsillitis. 

In the severe secondary cases the nose and pharynx should be syringed 
with a warm saline solution every two hours by day and every four hours 
by night. Where the swelling and oedema are great, benefit may result 
from frequent spraying with solutions containing adrenalin, also from 
inhaling hot vapour impregnated with eucalyptol, benzoin, etc. As an 



298 DISEASES OF THE DIGESTIVE SYSTEM. 

external application, whenever there is great adenitis and cellulitis, 
nothing is so beneficial as the ice-bag. 

The general management of these cases as to feeding, stimulants, 
etc., is the same as in diphtheria. Aside from stimulants no internal 
medication should be attempted with young children. Those who are 
older may take with advantage tr. ferri chlor., gtt. v to x, with glycerin, 
every three or four hours. 

ULCERO-MEMBRANOUS TONSILLITIS. 

(Vincent's Angina.) 

This is an inflammation somewhat resembling croupous tonsillitis, 
but it is often unilateral and associated with superficial ulceration. The 
tonsil is covered with a dirty yellowish exudation, which may be mistaken 
for diphtheria. There is superficial necrosis, and when this tissue is 
wiped away with a swab, bleeding occurs. The disease is further dis- 
tinguished by the swollen lymph nodes at the angle of the jaw, and by 
the fact that the constitutional symptoms which accompany other forms 
of tonsillitis are either very slight or absent altogether. The etiology 
is similar to, if not identical with, ulcerative stomatitis, with which it is 
sometimes associated. At such times the breath is foul and there is 
often profuse salivation. 

Ulcero-membranous tonsillitis was first described by Vincent, and 
by him attributed to a fusiform bacillus which he described, although a 
spirillum was found associated with it. Vincent's observations have been 
confirmed, and it has been shown that the spirillum is a degenerative 
form of the bacillus. 1 

The chief interest in ulcero-membranous tonsillitis lies in the diag- 
nosis, although it is not an infrequent disease. It is to be treated, like 
ulcerative stomatitis, by the internal administration of chlorate of pot- 
ash, combined with the local application of some antiseptic, such as 
peroxide of hydrogen or a ten-per-cent solution of nitrate of silver. 

FOLLICULAR TONSILLITIS. 

This is the most frequent and most characteristic form of inflamma- 
tion of the tonsil. It is essentially an inflammation of the tonsillar 
crypts, and secondarily of the whole glandular structure. 

1 Vincent's bacillus is about twice as long as the Klebs-Loeffler bacillus. It is thin, 
with pointed ends, and sometimes bent; it is negative to Gram's stain. The fusiform 
bacillus is occasionally found alone; the spirillum, never alone. The bacillus is found 
in smears from the affected tonsil, in making which it is recommended to go deeply 
into the necrotic tissue, since the superficial parts are crowded with other bacteria. 
It i3 grown with difficulty and only upon special culture media. 



FOLLICULAR TONSILLITIS. 299 

Etiology. — There is seen in certain children a predisposition to at- 
tacks of tonsillitis, so that from very slight exciting causes these occur — 
sometimes from exposure, sometimes possibly from derangement of the 
stomach, and sometimes without any evident reason. Children with a 
rheumatic -inheritance appear to be more susceptible than others. One 
attack predisposes to a second. Patients suffering from chronic hyper- 
trophy of the tonsils are exceedingly prone to acute tonsillitis. It is not 
very common in infancy, but after this period it is very frequent through- 
out childhood. The disease, in all probability, begins as an infectious 
inflammation at the bottom of the crypts, due to the presence of strep- 
tococci or staphylococci, which readily enter from the mouth, and excite 
an attack whenever favourable conditions are present. 

Lesions. — As a result of the inflammation, the tonsillar crypts are 
filled with epithelial cells, pus cells, mucus, and bacteria. These form 
masses which appear at the mouth of the crypts as small yellow dots, 
often miscalled ulcers. Sometimes, in addition, fibrin is poured out, 
and forms, with the other inflammatory products, little plugs which 
project somewhat from the surface of the mucous membrane, and which 
can easily be pressed out. Accompanying the changes in the mucous 
membrane above mentioned, there are acute congestion and swelling of 
the whole tonsil, with more or less proliferation of the lymphoid tissue. 
Follicular tonsillitis is almost always bilateral. Although the patholog- 
ical process is generally limited to the tonsils, there may be more or 
less pharyngitis associated. 

Symptoms. — The general symptoms usually appear before the local 
ones, and are often quite severe. The onset is abrupt, with chilly sensa- 
tions, occasionally a distinct rigor. In infants there is often vomiting, 
and sometimes diarrhoea. There is pain in the back, in the muscles of 
the extremities, and in the head. Sometimes there is pain in the lateral 
cervical muscles. The temperature rises rapidly to 102° or 103° F. ; 
often it touches 10-i° or 105° F. 

The first local symptoms are some swelling of the tonsils and the ap- 
pearance upon them of isolated yellow spots a little larger than a pin's 
head. Often these can be wiped off with a swab, or the little plugs can be 
squeezed out, leaving slight depressions. Later there is acute congestion 
of the tonsil, with more swelling. Even when the disease is at its height 
the local pain and discomfort may be only moderate, and in many cases 
scarcely noticeable. The -swelling and tenderness of the lymph glands 
behind the angle of the jaw are not great, and may be absent. 

The constitutional symptoms, as a rule, last three days, and are most 
severe upon the first day. The local symptoms last somewhat longer, but 
usually by the end of the fourth day the exudate has disappeared, 
although enlargement of the tonsil may persist for a week or even longer. 
On account of the connection of tonsillitis with rheumatism, the heart 



300 DISEASES OF THE DIGESTIVE SYSTEM. 

should be watched during attacks, especially in those who are subject 
to them. 

Diagnosis. — Tonsillitis may be confounded at its onset with scarlet 
fever. The great frequency of tonsillitis makes inspection of the throat 
imperative in every case of acute illness in children. The diagnosis from 
diphtheria is considered in connection with that disease. 

Treatment. — Follicular tonsillitis is a mild disease without danger to 
life, and one which runs a short, self-limited course. The indications 
are, therefore, to make the patient as comfortable as possible by the 
relief of individual symptoms. Older children, particularly those who 
are rheumatic, should be treated with sodium salicylate, or aspirin, four 
or five grains every three hours being given for the first twenty-four 
hours, and later less frequently. To infants these drugs must be given 
in smaller doses and with care, lest they upset the stomach. The general 
muscular pains of the first day are best relieved by phenacetine, two 
grains every four hours to a child three years old. Later it may be 
used in smaller doses, but enough should be given to make the patient 
comfortable. 

Local treatment is better omitted with infants. Older children may 
gargle with a solution of boric acid or may use a spray of DobelPs solu- 
tion. Benefit often follows painting the tonsils with tincture of iodine 
or a ten-per-cent solution of silver nitrate. In all doubtful cases the 
patient should be isolated and the same general treatment adopted as in 
diphtheria. 

PHLEGMONOUS TONSILLITIS— PERITONSILLAR ABSCESS— QUINSY. 

This is an inflammation of the cellular tissue surrounding the tonsil, 
sometimes invading the tonsil itself. It may terminate in resolution, but 
usually goes on to the formation of an abscess. Phlegmonous tonsillitis 
is much less common in children than in adults, and, compared with the 
other forms, it is a rare disease in early life. It is the only variety which 
is regularly unilateral. In most cases the inflammatory process is cir- 
cumscribed, but in rare instances there is seen a diffuse phlegmonous 
inflammation of the pharynx. 

In certain patients there exists a constitutional predisposition to the 
disease, which ma}' be associated with rheumatism. The exciting cause 
may be exposure, or anything which may reduce the patient's general 
health, to which there is added local infection. Catarrhal pharyngitis 
predisposes to this disease. 

Symptoms. — The onset resembles that of follicular tonsillitis, the 
temperature is often high, and the muscular pains and prostration severe. 
There is very severe pain in the throat, which is increased by deglutition, 
and finally may be so great that swallowing is almost impossible. It is 
difficult to open the mouth. There is pain in the lateral muscles of the 



CHRONIC HYPERTROPHY OF THE TONSILS. 301 

neck, and often tenderness. In the beginning but little can be seen on 
inspection, even though the patient complains of a very sore throat. This 
is always a suspicious circumstance, and should lead one to look out for 
quinsy. It is due to the fact that the inflammation begins in the deeper 
tissues, and that the mucous membrane is affected later. After twenty- 
four or forty-eight hours there is usually quite marked swelling, which 
is rather more behind the tonsil than elsewhere, pushing it upward and 
forward ; sometimes it is more in front of the tonsil. A little later there 
is intense inflammation of the mucous membrane covering the tonsil, 
fauces, and uvula, and not infrequently a fibrinous exudate ; the uvula may 
be pushed to one side, and the isthmus of the fauces diminished to less 
than one-half its natural size. In one of my own cases marked torticollis 
was present, and existed for two or three days before the diagnosis of 
quinsy could be made by the other symptoms. 

In most cases the recognition of quinsy is quite easy by attention to 
the symptoms above mentioned. By inspection of the throat, less in- 
formation is sometimes obtained than by palpation; by this means a 
fulness, and later a point of fluctuation, can readily be made out. Acute 
phlegmonous tonsillitis generally involves no danger to life. In very 
young infants serious results may follow spontaneous rupture during 
sleep; and in older children occasionally there may be oedema of the 
glottis. If not treated, abscess usually forms in from five to seven days, 
and opens spontaneously. 

Treatment. — If an early diagnosis is made an attack of quinsy may 
possibly be aborted. For this many drugs have been advocated, but 
to my mind the best is salol, which should be given in doses of two 
grains every two hours to a child of five years. In some patients larger 
doses may be used. This may be combined with small doses (gr. J) of 
Dover's powder. Relief may be afforded by very hot or cold applications, 
according to the sensations of the patient. The holding of ice in the 
mouth and the application of an ice-bag externally, often give great 
comfort. In other cases, gargling with very hot water and the applica- 
tion of hot flaxseed poultices externally, will be preferred. As soon as 
fluctuation is detected an incision should be made with a guarded bis- 
toury. If made too early, only a small amount of pus is evacuated and 
the abscess may refill. After spontaneous rupture the relief to symp- 
toms is usually immediate. 

CHRONIC HYPERTROPHY OF THE TONSILS.— CHRONIC TONSILLITIS. 

The condition known as chronic hypertrophy is a permanent enlarge- 
ment due to a proliferation of the lymphoid tissue of the tonsils, and an 
increase in the connective-tissue stroma. If the increase in the con- 
nective tissue is slight, the tonsil is soft; if it is great, the tonsil is firm 



302 DISEASES OF THE DIGESTIVE SYSTEM. 

and hard, almost like a fibrous tumour. All degrees are found. Asso- 
ciated with hypertrophy of the tonsils there are usually found adenoid 
growths of the pharynx, both of these depending upon similar local and 
constitutional conditions. There is in nearly all marked cases a chronic 
pharyngeal catarrh which may involve the Eustachian tubes. 

Etiology. — Hypertrophy of the tonsils is an exceedingly common con- 
dition in the cities of the seacoast and lake districts of the temperate 
zone. In a routine examination of 2,000 New York school children, 
Chappell found enlargement of the tonsils sufficiently marked in 270 
cases to be considered pathological. The causes are constitutional and 
local. The condition frequently exists in certain families for several 
generations. It is not connected with tuberculosis. It occurs in children 
who are in other respects. healthy. Hypertrophy of the tonsils is often a 
congenital condition, increasing slowly during infancy, so as to produce 
marked symptoms by the time the child is two }^ears old. The most 
important of the local causes are attacks of acute or subacute pharyngitis. 
While it is true that attacks of acute inflammation are often the cause of 
hypertrophy, it is also true that hypertrophy is one of the most frequent 
predisposing causes of acute attacks, and that it may be seen in children 
who have never had tonsillitis. 

Symptoms. — Hypertrophy of the tonsils is rarely marked enough to 
cause any decided sjTriptoms before the end of the second }^ear, although 
I once saw in a younger child enlargement sufficient to bring the two 
tonsils into contact. The most important local symptoms, formerly 
ascribed to hypertrophied tonsils, are now known to depend upon adenoid 
growths of the pharynx. As these conditions are so frequently associated, 
it is somewhat difficult to determine which symptoms are due to the 
tonsils alone. In a marked case, the most prominent symptoms are 
mouth-breathing, disturbed sleep accompanied by snoring, and nasal 
voice — the patient in some cases talking as though he had food in his 
mouth. There may be some difficulty in swallowing solid food. En- 
larged tonsils may often be felt externally. As a consequence of the 
obstruction of the Eustachian tubes there may be deafness. Deformities 
of the chest, such as pigeon-breast, are occasionally seen, but probably 
depend more upon obstructed respiration by adenoids than by the tonsils. 

The soft tonsils may diminish somewhat in size spontaneously. They 
sometimes shrink very decidedly after an attack of acute tonsillitis, 
scarlet fever, or diphtheria. As a rule the tonsils become firmer and 
harder as time passes. They usually increase in size up to a certain 
point, and then remain nearly stationary until about puberty, when 
they may diminish considerably. During intercurrent attacks of inflam- 
mation, the swelling is much increased, and the symptoms are propor- 
tionately aggravated. In cases of marked enlargement very little spon- 
taneous improvement is to be looked for during childhood. 



CHRONIC HYPERTROPHY OF THE TONSILS. 303 

Treatment. — Very large tonsils are a source of continued danger to 
the patient, and in every case of marked hypertrophy treatment should 
be advised. The danger may be from Eustachian catarrh and deafness, 
or from repeated attacks of acute tonsillitis. But quite as important as 
these is the fact that they increase the liability to contract diphtheria, 
and add to the dangers both from diphtheria and scarlet fever. If the 
patient is removed from the locality in which acute tonsillitis is liable to 
occur, to a dry climate, considerable improvement is likely to result in 
a young child in whom the tonsils are soft, but not much is to be 
expected in older children with hard, fibrous tonsils, except, perhaps, a 
cure of the accompanying pharyngeal catarrh. 

No internal remedy offers much chance of benefit. Astringent ap- 
plications may accomplish something in recent, but practically nothing 
in old cases. In every marked case, operation is the only thing which 
can be relied upon to effect a cure. For convenience of consideration, 
the cases may be divided into three groups : ( 1 ) Those in which the 
tonsils are nearly or quite in contact; (2) those in which they project 
only slightly beyond the faucial pillars; (3) those in which the tonsils, 
although large, are deeply imbedded. All of the first group should un- 
questionably be operated upon, unless the patient's general condition is 
such as to forbid operation of any kind. In the second group operation 
is not indicated unless there are repeated acute attacks, or the tonsils are 
the seat of chronic infection. Whether an operation is done in the 
third group will depend upon the individual case. If there are frequent 
attacks of acute tonsillitis or evidence of involvement of the ears opera- 
tion should be performed. 

Various operations are in use for the removal of hypertrophied ton- 
sils: the wire snare, amputation with the guillotine, and enucleation. 
Each has its advocates and each its advantages. The use of the snare 
is accompanied with little risk of haemorrhage. It is a painful opera- 
tion, some preliminary dissection is usually required, and hence general 
anaesthesia is necessary. Amputation by the guillotine is simpler and 
for well-projecting tonsils quite sufficient. The risk of haemorrhage in 
children is slight. An anaesthetic is unnecessary if only the tonsils 
are to be removed. The amount of shrinkage from cicatrisation after 
operation has been, in my experience, generally less than was expected. 
Enlargement of the tonsil subsequent to amputation is sometimes seen, 
oftener if the patient operated on is under two years old. I am not 
yet convinced of the advantages of complete enucleation, now much in 
vogue, as a routine operation for hypertrophied tonsils, but in certain 
cases nothing else is adequate. Such are the broad, deeply imbedded, 
adherent tonsils. Excessive haemorrhage after any form of operation 
may be controlled by digital pressure, or by the application of styptic 
cotton upon a swab; in extreme cases, by transfixing the tonsil stump 



304 DISEASES OF THE DIGESTIVE SYSTEM. 

with a harelip pin and the application of a Ligature. I have more than 
once Been physicians greatly alarmed at the gray wound on the day fol- 
lowing tonsillotomy, the appearance being such as to lead in several cases 
to the diagnosis o( diphtheria. It is seldom that any but good results 
follow the operation o( tonsillotomy if properly performed. When ade- 
noids oi the pharynx are also present, the symptoms may depend more 
upon them than upon the enlarged tonsils, and little benefit is seen un- 
less the adenoids also are removed. 



CHAPTER IV. 

DISEASES OF THE (ESOPHAGUS. 

MALFORMATIONS. 

CONGENITAL anomalies of the oesophagus are often associated with 
those of the lower part of the respiratory tract. 

There may be, ( 1 ) Congenital fistula of the neck, due to a want of 
closure between the second and third branchial arches. This gives a:i 
external opening just above and to the outside of the sterno-clavicular 
articulation, which communicates with the upper part of the oesophagus 
or the lower part of the pharynx. (2) The oesophagus ma}^ be absent, 
the pharynx ending in a blind pouch. (3) The oesophagus may be oblit- 
erated in certain portions, being represented only by a fibrous cord. (4) 
There may he stenosis and dilatation or diverticula. (5) There may be 
fistulous communication with the trachea, existing either alone or asso- 
ciated with some of the other deformities mentioned. 

Congenital narrowing of the oesophagus and fistula of the neck are 
amenable to surgical treatment. The cases of complete obstruction in 
the oesophagus are almost of necessity fatal, the patients dying from in- 
anition two or three days after birth. 

The symptoms of oesophageal obstruction are regurgitation on at- 
tempts at swallowing and the impossibility of passing the stomach tube. 
An X-ray picture after the administration of bismuth often gives valu- 
able information. 

ACUTE OESOPHAGITIS. 

It is quite remarkable, considering the frequency of pathological 
processes in the pharynx, that these so rarely extend to the oesophagus. 
Thrush, when very extensive in the pharynx, may involve the upper part 
of the oesophagus; but there it gives rise to no new symptoms. Diph- 
theria of the pharynx may invade the oesophagus, but this is seen, only 
in rare instances. Diphtheria of the oesophagus produces no symptoms 
by which it can be diagnosticated during life. 



RETRO-CESOPHAGEAL ABSCESS. 305 

Catarrhal (Esophagitis. — Catarrhal oesophagitis is very rarely met 
with. It may be caused by lacerations due to swallowing a foreign body, 
which may excite a simple catarrhal inflammation, or, if the foreign 
body is sharp and angular, lacerations may be produced which result in 
ulcerations of variable depth. The chief symptoms of catarrhal oesoph- 
agitis are soreness and pain on swallowing. These lacerations, when 
slight, are healed in a few days, and are rarely followed by any after- 
effects. 

Corrosive (Esophagitis. — This is altogether the most frequent form, 
and the only one which is of clinical importance. The usual causes are 
the same as of corrosive gastritis, viz., the swallowing of caustic alkalies 
or strong acids. It is often in the oesophagus that the most extensive 
injury is done. The effects are superficial or deep, according to the 
amount of the irritant swallowed and its degree of concentration. There 
may be simply a destruction of the epithelial layer, which is followed by 
no serious consequences, or the mucous membrane may be destroyed and 
the submucous coat invaded; rarely, however, does the injury extend to 
the muscular layer. If the patient survives the dangers incident to the 
irritant poisoning and the acute inflammation which follows, healing by 
granulation and cicatrisation takes place, the contraction of the cicatrix 
gradually narrowing the lumen of the oesophagus until stricture is pro- 
duced. 

The early symptoms of corrosive oesophagitis are mingled with those 
of inflammation of the mouth, pharynx, and stomach. There is a burn- 
ing pain in the parts, great thirst, and spasm of the oesophagus on at- 
tempts at swallowing. There follows a period of acute inflammation of 
several days' duration, with great dysphagia and pain, in which the 
principal danger is oedema of the glottis. After this the patient may 
be comparatively well until the symptoms of stricture begin, usually in 
from three to six months after the injury. 

The indications for treatment in the early stages are, to neutralise the 
caustic in order to prevent if possible its deep action, to give oils, demul- 
cent drinks and ice for the local effect, and morphine for the pain. 

The treatment of oesophageal stricture is purely surgical. 

RETRO-CESOPHAGEAL ABSCESS. 

Acute retro-cesophageal abscess occurs in infancy, though very rarely, 
the pathology being the same as in acute retro-pharyngeal abscess, the 
difference being merely one of location. A striking case of this kind 
occurred in the New York Foundling Hospital. An infant six months 
old was admitted with high fever (104° F.), severe dyspnoea, but with no 
loss of voice, which were the prominent symptoms until death occurred 
four days later. There was a leucocytosis of 100,000. At autopsy an 
21 



306 DISEASES OF THE DIGESTIVE SYSTEM. 

abscess was found containing about three ounces of pus between the 
oesophagus and the spine, extending from the larynx to below the bifur- 
cation o( the trachea. Shortly afterward 1 saw a very similar case at the 
Babies' Hospital, following a retro-pharyngeal abscess which had been 
opened two weeks before. Similar abscesses have also been observed after 
acute pharyngitis with the acute infectious diseases. 

Retro-oesophageal adenitis, or enlargement of the lymph nodes in 
this situation without suppuration, is also rare. I once met with a case 
of this *ort in which the gland formed a tumour nearly an inch in diam- 
eter at the upper part of the oesophagus, causing pressure symptoms 
necessitating tracheotomy. The growth was at first thought to be malig- 
nant, but completely disappeared after a summer in the country. 

Eetro-oesophageal abscess may result from the breaking dowm of 
tuberculous lymph nodes in the posterior mediastinum, and may give rise 
to symptoms like those which result from an abscess due to Pott's disease. 

Perforation of the oesophagus and a food-fistula connecting the oesoph- 
agus and the trachea may result from ulceration caused by a tracheal 
canula or by a foreign body. This may be accompanied by abscess. 

The most common variety of retro-cesophageal abscess is that due to 
Pott's disease of the lower cervical or upper dorsal region. The symp- 
toms are obscure, and an exact diagnosis is not often made during life. 
Death may occur quite suddenly where the previous symptoms have been 
so slight as to be easily overlooked. The following is a fair example : 

A girl two years old was admitted to the Babies' Hospital with caries 
of the upper dorsal region of two months' duration. The patient was 
kept in bed and a plaster-of -Paris jacket applied. About a month later 
dyspnoea was first observed; this was at times quite intense, and again 
almost absent. It was always on inspiration, expiration being easy. Xo 
explanation for this was found in the lungs. There was no difficulty in 
swallowing, and very little cough. After these symptoms had lasted for 
about a week, the child while eating was suddenly seized with violent 
dyspnoea, and in a few moments became completely asphyxiated. Trache- 
otomy was immediately done, and by means of artificial respiration the 
patient was restored to comparative comfort. About two hours later a 
second attack occurred, and the patient died in an hour. At the autopsy 
there was found an abscess a little larger than a hen's egg, containing 
about two ounces of curdy pus, overlying the bodies of the first three 
dorsal vertebrae and communicating with them. These vertebrae were 
carious. The right pneumogastric nerve, an inch and a half above the 
bi furcation of the trachea, was compressed between the abscess and a 
large tuberculous lymph node, with the capsule of which it was blended. 
In the lungs were a few small tuberculous deposits and the usual condi- 
tions found in death by asphyxia. The dyspnoea seems to have been of 
nervous and not of mechanical origin, and caused by irritation of the 



RETRO-CESOPHAGEAL ABSCESS. 307 

pneumogastric. The fatal issue was apparently from an increase of the 
pressure upon the nerve. 

I have seen but one other case, and this closely resembled the one 
reported. In the thirteen cases collected by Griffith the symptoms in all 
were much alike. Dyspnoea, usually of a spasmodic character, was 
prominent in nearly all, and generally it was the most marked symp- 
tom. It was more marked on inspiration, and often accompanied by a 
spasmodic cough, suggesting laryngeal stenosis. The voice was affected 
in but two cases, in one complete aphonia being present. It is striking 
that in no case was there any difficulty in swallowing, in marked con- 
trast to retro-pharyngeal abscess. Swelling in the neck was noted in but 
three cases. Spinal caries was stated to be present in seven cases and 
absent in two. The final attack of asphyxia sometimes came without 
warning, sometimes was preceded for several days or longer by milder 
attacks. 

The diagnosis of this condition is very difficult, and a positive diag- 
nosis almost impossible. It may be suspected in cases of Pott's disease 
of the lower cervical or upper dorsal regions, when there is spasmodic 
inspiratory dyspnoea, especially if accompanied by irritative cough. • It 
should, however, be remembered that precisely similar symptoms may 
depend upon the irritation of a tuberculous node, and that the sudden 
asphyxia is exactly like that caused by the ulceration of such a node 
into the trachea or a large bronchus. The latter, however, may occur 
without the presence of Pott's disease. If the abscess is higher up, there 
may be a lateral swelling on either side of the neck, just above the clav- 
icle. In most of the cases there are no external signs of disease. Such 
abscesses are too low to be reached by digital examination of the pharynx. 
The attack of asphyxia may also be confounded with that due to the 
presence of a foreign body in the larynx. 

The prognosis in cases of retro-cesophageal abscess is exceedingly bad. 
Death usually results from pressure upon the pneumogastric, as in the 
cases reported. The abscess may rupture into the oesophagus and recov- 
ery follow. This termination is very rare, but such a case has been re- 
ported by Knight. A fatal one is reported by Loschner and Lambl. The 
abscess may burrow along the oesophagus into the abdominal cavity and 
excite peritonitis ; finally, it may open externally. 

But little is to be said under the head of Treatment. The symptoms 
are rarely definite enough to justify a radical surgical operation. Trache- 
otomy gives but temporary relief to the asphyxia. This operation should 
be performed, however, in every case, because of the impossibility of 
making a diagnosis of retro-cesophageal abscess from other condition* 
in which the operation might be curative. 



308 DISEASES OF THE DIGESTIVE SYSTEM. 

CHAPTER V. 

DISEASES OF THE STOMACH. 

It is difficult wholly to separate diseases of the stomach from those 
of the intestine. Although in older children they are often quite dis- 
tinct, in infancy they are more frequently associated; but at one time 
the gastric symptoms may be prominent, and at another the intestinal 
symptoms. Functional disorders particularly are likely to involve the 
whole tract. Serious organic lesions are more frequently limited in 
their extent either to the stomach or to the intestine. The former are 
rare, while the latter are very common. The diseases in which the stom- 
ach is alone or chiefly involved will be considered by themselves. Those 
in which both the stomach and intestine are involved are classed with 
the intestinal diseases, as the intestinal symptoms usually predominate. 

DIGESTION IN INFANCY. 

The first step in the process of digestion in the newly-born infant is 
sucking. During this act the nipple is grasped between the lower lip and 
tongue below, and the upper lip and jaw above. The back of the mouth 
is closed by the palate. A strong downward movement of the lower jaw 
causes a partial vacuum in the mouth, and produces the suction force 
which causes the milk to flow. Sucking can be carried on only when the 
nose is free for respiration and the palate and upper jaw intact. Chil- 
dren with deformities of the mouth, like cleft palate and harelip, suck 
only with the greatest difficulty, and complete nasal obstruction prevents 
nursing. 

The Saliva. — This is present at birth only in very small amount, and 
the part which it plays in digestion in early infancy is an insignifi- 
cant one. During the third and fourth months it increases markedly in 
quantity, and at this time it possesses quite actively the power of trans- 
forming starch into sugar. This property is present only to a very slight 
degree during the early weeks. 

The Stomach. — The position of the stomach in the foetus is nearly 
vertical. In the newly-born child it lies somewhat obliquely in the abdo- 
men, and at the end of infancy has almost reached the transverse posi- 
tion. The stomach at birth is nearly cylindrical, but the fundus increases 
in size rapidly during the first year, although it does not reach its full 
development until quite late in childhood. In Plate VII are shown the 
actual size and shape of the stomach at various periods. In the follow- 
ing table are given the results of post-mortem measurements of the 
stomach, which I have personally made in ninety-one infants under 
fourteen months of age: 



PLATE VII. 



* 3 

c o 



o 

— 

Oh 

g 

3 





DIGESTION IN INFANCY. 



309 



The Capacity of the Stomach. 



Age. 


Number 
of cases. 


Average 
capacity. 


Age. 


Number 
of cases. 


Average 
capacity. 


Birth 


5 
7 
4 
11 
4 
2 


1.20 oz. 
1.50 " 
2.00 " 
2.27 " 
3.37 " 
4.25 " 


1 

12 weeks 

14 to 18 weeks . . 
5 to 6 months . . 
7 to 8 " ... 
10 to 11 " ... 
12 to 14 " ... 


6 
12 
14 

9 

7 
10 


4 50 oz 


2 weeks 

4 " 

6 " 

8 " 

10 " 


5.00 " 
5.75 " 
6.88 " 
8.14 " 
8.90 " 



In brief, the average capacity was, at birth, one and one-fifth ounces ; 
at three months, four and a half ounces; at six months, six ounces; at 
twelve months, nine ounces. 

Gastric Digestion. — The part taken by the stomach in digestion is 
not so important in infants as in adults. The function of the stomach 
is largely that of a reservoir, into which the milk is received and from 
which it is allowed to pass gradually into the intestine; the gastric pro- 
cess is only a preliminary and partial one, even in the digestion of pro- 
tein, this being completed in the intestine. 

The gastric juice acts chiefly upon the protein of the food; the 
digestive agents being pepsin and hydrochloric acid. It is pretty well 
established that protein digestion in the stomach does not go beyond the 
stage of peptone formation. The amount of gastric juice secreted is 
very large. In experiments upon animals it has been found to be nearly 
as great as the volume of milk taken. 

Pepsin is found in the stomach at birth, and even in the foetus as 
early as the fourth month. In fifteen minutes after feeding the reaction 
of the stomach contents is always acid. Free hydrochloric acid can not 
usually be demonstrated until about an hour after feeding, then only in 
small quantities, and in very many cases not at all. The reason for this 
is, that the acid combines with the casein and the salts of milk, those of 
cow's milk in particular having a great power of combining with hydro- 
chloric acid. 

The coagulation of milk in the stomach is accomplished through the 
agency of the rennet ferment. Many good authorities consider that this 
is not a separate substance, but that coagulation is one of the properties 
of pepsin. Coagulation is the first change which the milk undergoes in 
the stomach. Woman's milk coagulates in loose flocculi and quite im- 
perfectly. Cow's milk, unless diluted, coagulates in firmer, rather com- 
pact masses. Under the influence of pepsin and hydrochloric acid, solu- 
tion of this coagulum now begins ; but this is only partially accomplished 
in the stomach. It goes forward much more rapidly in the case of wom- 
an's milk, because the amount of casein is less and because of the smaller 
curds. The fluid portion of the milk begins to leave the stomach very 
soon after the meal, and even during the first half hour a considerable 



310 DISEASES OF THE DIGESTIVE SYSTEM. 

part passes into the intestine. At the end of an hour the stomach in a 
young infant is often empty. If the food is cow's milk, not only are the 
coagula firmer, but the amount of casein present is much larger, and 
hence the milk is retained in the stomach a considerably longer time; 
even then some of it passes but little changed into the intestine. The 
existence o( a fat-splitting ferment in the stomach of infants is now 
generally admitted, though it plays but a small role in digestion. 

The duration of gastric digestion varies with the age of the infant 
and with the food. During the first month the stomach of healthy 
nursing infants is usually found empty in an hour and a half after feed- 
ing, often in one hour. In those taking cow's milk the average is at 
least one hour longer. In infants from two to eight months old the 
average is two hours for those receiving breast-milk, and two and a half 
to three hours for those fed upon cow's milk. The time is influenced by 
the size of the meal taken and by the composition of the food. The 
water and milk sugar first pass into the intestine, then the protein in 
various stages of digestion, and, lastly, the fat. The higher the propor- 
tion of fat in the meal the longer the food is retained in the stomach, 
and also the smaller the amount of gastric juice secreted. Very little 
absorption takes place from the stomach. There is here absorbed a cer- 
tain proportion of the sugar and salts, and a small amount of the nitrog- 
enous material, but practically no water or fat. 

The bacteria of the stomach are very few as compared with those of 
the intestine, and no varieties are constantly present. 

The Intestines. — The length of the small intestine at birth is about 
nine feet; that of the large intestine about eighteen inches. The great 
length of the sigmoid flexure is the most striking peculiarity, this being 
nearly one-half the length of the large intestine. 

Intestinal Digestion. — All the important elements of food — protein, 
carbohydrates, and fat — are acted upon by the pancreatic juice. The 
protein is converted into peptones by trypsin. How much of the protein 
of the milk is left for intestinal digestion, depends upon how well the 
stomach has done its part. In every case something is left; in most 
cases a large part of the protein passes but little changed into the in- 
testine. The digestion of protein is completed by the erepsin of the 
intestinal juice, which converts peptones and albumoses into amino acids. 
In this form the nitrogenous portion of the food is finally absorbed. 

The amylolytic ferment of the pancreas has the power of converting 
starch into maltose. This action is feeble during the first five or six 
months, but is present even in early infancy. Milk sugar is changed into 
galactose and glucose ; and cane sugar and maltose into glucose through 
the agency of the intestinal and pancreatic juices. Fats are partly emul- 
sified and partly saponified by the pancreatic juice in connection with 
the bile. 



DIGESTION IN INFANCY. 311 

Absorption. — From the small intestine absorption takes place very 
rapidly. The protein is absorbed in the form of peptids and amino acids. 
Sugars of all varieties are changed to glucose during absorption. Fat is 
absorbed in the form of fatty acids and soaps; but in their passage 
through the wall of the intestine the fatty acids are converted into 
neutral fats. Absorption from the large intestine, except of water, is 
quite imperfect. Fat absorption is very slight. Sugar, salts, and pep- 
tones, however, may be absorbed with moderate facility. 

Intestinal Bacteria. — For the fundamental work upon this subject we 
are indebted to the researches of Escherich. Bacteria are absent from 
the entire gastro-enteric tract at birth. They quickly enter by the mouth 
and rectum, and by the end of twenty-four hours they are usually found 
in all parts of the intestinal tract. The meconium-bacteria are derived 
from the inspired air, and hence vary somewhat with surroundings. As 
soon as the ingestion of milk begins these varieties are displaced, and 
throughout the period in which the infant has this food exclusively, there 
have been found in healthy conditions but few varieties which are con- 
stantly present. These are the b. lactis aerogenes, the b. coli communis, 
and the b. bifidus. The number of bacteria vary in different parts of the 
intestine. They are found in greatest numbers in the caecum and colon, 
and are relatively few in the small intestine. The b. lactis aerogenes 
is found most abundantly in the upper part of the small intestine, in 
small numbers only in the colon, and usually there are none in the 
faeces. 

The b. coli communis is found in but small numbers in the upper 
small intestine, becoming more abundant lower down. In the colon and 
in the faeces it is present in considerable numbers. The most abundant 
organism in the large intestine, however, is the b. bifidus. A change 
from a milk diet to a mixed diet of meat and farinaceous food produces 
a marked change in the character of the intestinal bacteria. 

Faeces. — The first discharges after birth are called meconium; this is 
of a dark brownish-green colour, semi-solid, and usually passed from 
four to six times daily during the first two or three days. On the third 
day the stools begin to change in character, and by the fourth or fifth 
day they have usually assumed the appearance of healthy milk-faeces. 
Under many abnormal conditions the stools may continue to have the 
character of meconium for a week or more. Meconium is composed 
of intestinal mucus, bile, the vernix caseosa, epithelial cells from the 
epidermis, hairs, fat-globules, and cholesterin crystals. For its forma- 
tion there are necessary the secretions of the intestine and the liver and 
the swallowing of a considerable amount of amniotic fluid. 

Milk-faces. — The normal amount of faeces discharged daily by a 
healthy nursing infant is from two to three ounces. Such stools have the 
colour of the yolk of egg. They are smooth, homogeneous, of a soft, but- 



312 DISEASES OF THE DIGESTIVE SYSTEM. 

ter-like consistency, with an acid reaction, and a slightly acid but not 
unpleasant odour. The reaction is due to the presence of fatty acids 
or lactic acid. The colour depends upon bilirubin. The stools of an 
infant fed upon cow's milk may, in conditions of perfect digestion, differ 
in no respect from those just described ; usually, however, they are firmer, 
of a paler yellow colour, and may be neutral or even alkaline in reaction. 
The normal stool contains about 85 per cent of water and 15 per cent of 
solids, of which the most important ingredient is fat. 

The only gases present are hydrogen and carbon dioxide. Sulphur- 
etted hydrogen and marsh gas, to which the odour of adult stools is 
largely due, are not present. 

The protein of both woman's and cow's milk is almost entirely ab- 
sorbed. The nitrogenous content of the normal stool is derived chiefly 
from the intestinal secretions and the bodies of the bacteria. 

Fat is always present, and forms from ten to thirty per cent of the 
dry residue of milk-faeces. It is present as neutral fat, fatty acids, and 
soaps. Sugar is not found, but its derivative, lactic acid, may be present 
in a small amount. Inorganic salts form about ten per cent of the dry 
residue. They are chiefly the salts of calcium. Of the biliary elements 
there are hydrobilirubin, unchanged bilirubin, and cholesterin in con- 
siderable amount. The presence of biliary acids is doubtful. Mucus is 
always present in considerable quantity. 

Microscopically there are seen epithelial cells, chiefly of the columnar 
variety, a few round cells, mucous corpuscles, fat globules and crystals of 
fatty acids, cholesterin, mucin, crystalline inorganic salts, sometimes 
bilirubin in crystals, yeast fungi, and bacteria in immense numbers. 

If the infant is taking a food containing starch, this may appear to 
a greater or less extent in the stools, a larger amount in the case of very 
young infants. 

The number of stools during the first two weeks is from three to six 
daily. After the first month two stools a day are the average; many 
infants have three, many others but one. 

As soon as an infant is put upon a mixed diet, the peculiar charac- 
ters of the stools disappear, and they come to resemble more closely those 
of the adult, though remaining softer throughout infancy. They be- 
come darker in colour and assume the adult odour, while retaining their 
acid reaction. The bacteria, while still in great numbers, are more 
varied than are met with in milk-faeces. 



MALPOSITIONS AND MALFORMATIONS OF THE STOMACH. 

The stomach is sometimes in the thoracic cavity in cases of diaphrag- 
matic hernia. It may be found in a vertical (foetal) position, variously 
adherent to the colon and small intestine. Malformations are much less 



HYPERTROPHIC STENOSIS OF THE PYLORUS. 313 

frequent than those of other parts of the alimentary tract. There may 
be atresia or stenosis at either orifice, and very rarely a constriction is 
found near the middle of the organ, dividing it into compartments. The 
symptoms of atresia at either orifice are persistent regurgitation or 
vomiting, and death in a few days from inanition. 

HYPERTROPHIC STENOSIS OF THE PYLORUS. 

This condition known also as pylorospasm and as congenital steno- 
sis of the pylorus, or simply as pyloric stenosis of infancy, is not an 
uncommon one. It is met with in early infancy and is characterised 
by persistent vomiting, constipation, wasting, marked visible gastric 
peristalsis, and often a palpable tumour. It is a serious condition, nearly 
one-half of the cases ending fatally. Little is known of its etiology. 
Fully four-fifths of the cases occur in males. It has no relation to the 
method of feeding; a large proportion of the recorded cases have been 
in nursing infants. The variety of names reflects the different theories 
which have been advanced to explain its occurrence. By some the con- 
dition is considered a primary hypertrophy with a secondary spasmodic 
element added; by others, as a purely spasmodic condition from gastric 
or duodenal irritation, possibly due to increased acidity; by still others 
the spasmodic condition is regarded as primary, with hypertrophy devel- 
oping secondarily. Pylorospasm has its analogue in other spasmodic 
conditions of the circular muscle fibres in early infancy. As examples 
may be mentioned : constipation due to a spastic condition of the sphinc- 
ter ani, intussusception due to irregular or intermittent muscular spasm 
of the intestines, and various spasmodic affections of the larynx and 
bronchi. 

The post-mortem findings are remarkably uniform. The pylorus 
appears as a hard, whitish tumour about the size of a peanut, of almost 
cartilaginous consistency. Its lumen may be so narrowed as barely to 
admit a fine probe, while the normal pylorus will usually admit a No. 21 
sound, French scale. Frequently water can not be forced through the 
stenosis owing probably to the fact that the mucous membrane is thrown 
into folds. The walls of the stomach are often hypertrophied, especially 
toward the pyloric end. The stomach is usually much dilated ; its lower 
border may be below the navel. There may even be some dilatation of 
the oesophagus. On section the thickening of the pylorus is seen to be 
chiefly of the circular muscle fibres. This coat appears to be two or 
three times the normal thickness. The other coats — submucous, mucous 
and longitudinal muscular — are thickened but to a much less degree. 

Symptoms. — The general clinical picture is a striking one. An in- 
fant who for the first two or three weeks has shown no signs of gastric 
disorder, and often has been nursing and gaining regularly in weight, be- 



314 DISEASES OF THE DIGESTIVE SYSTEM. 

urns to vomit : at lirst occasionally, but soon habitually. The change from 
the usual typo o( vomiting to the forcible and constant vomiting is often 
abrupt and without evident cause. The vomiting is not the ordinary 
gastric regurgitation of indigestion but is forcible and projectile. Changes 
in diet have but a temporary effect upon it, or none at all. The bowels 
are constipated. The infant wastes steadily, the scales often showing 
a loss o\' one or two ounces a day. There is no fever and little or no 
evidence of pain. There is progressive failure in nutrition and death 
may occur from exhaustion in from four to six weeks from the beginning 
of marked symptoms. 

Time of Beginning of Symptoms. — Exceptionally this is in the first 
week or even in the first days of life. The average time, however, is 
after the first week and during the first month, very rarely as late as 
the . sixth or seventh week. 

Vomiting. — The manner of vomiting is characteristic. It is more 
forcible than that seen under any other condition. I have often seen 
an infant fairly shoot out the contents of the stomach to a distance of 
four or five feet. Food frequently comes through the nose. The vomit- 
ing has usually a relation to the taking of food. It most frequently 
comes directly after the meal, often while the child is still at the breast. 
After an attack of vomiting, nursing is sometimes resumed with avidity, 
showing a distinct absence of the usual symptoms of gastric indigestion. 
All the food is generally expelled at one time. The frequent regurgita- 
tion of small amounts is seldom seen. Generally vomiting does not 
occur at night unless the child is nursed at that time. The vomited 
matters at first consist only of food, often but little changed. After a 
time there is mucus, sometimes in large quantities. The amount vomited 
at one time is often considerably greater than the meal just taken, 
indicating a considerable retention of food in the stomach. Some of 
these children vomit regularly after every feeding; others retain two 
or three feedings and then expel the whole amount. The frequency of 
vomiting varies from once or twice to six or eight times a day. Owing 
to the loss of fluid by vomiting the urine is usually very scanty. There 
is no uniform change in the gastric secretions, but there is frequently 
hyperacidity present. 

Bowels. — Obstinate constipation is the rule. If the pyloric obstruc- 
tion is complete the stools resemble meconium. Exceptionally diarrhoea 
is present. I have seen it in but a single case and here the obstruction 
was not complete. 

Wasting. — Progressive wasting is one of the striking symptoms, and a 
close observation of the weight one of our best guides to the progress of 
the case. If the loss is only two or three ounces a week the outlook is 
hopeful ; while if this amounts to two or three ounces a day the condition 
should be considered most critical. The rate of the loss depends natur- 



HYPERTROPHIC STENOSIS OF THE PYLORUS. 315 

ally upon the completeness of the obstruction and it is proportionate to 
the amount of vomiting and the degree of constipation. 

General Appearance. — At first nothing abnormal is seen, but soon 
all the evidences of rapid malnutrition are present, without, however, the 
other usual symptoms of indigestion, such as might be expected with the 
vomiting. The tongue is usually clean; the appetite often voracious; 
there are no eructations of gas; the breath is sweet. 

Peristalsis. — On examination of the abdomen the epigastrium is 
usually full and the lower half of the abdomen sunken. If the skin is 




Fig. 49. — Gastric Peristalsis in Pyloric Stenosis. (Thomson). 
Patient eight weeks old. 

bared and the patient placed in a good light the characteristic peristaltic 
waves are seen which are the most diagnostic feature of the disease. 
One should not expect to see them if the stomach is empty; they are 
best seen immediately after taking food or water. When not appearing 
spontaneously they may often be excited by slight friction or tapping of 
the epigastrium. There is seen a slowly moving wave from left to right. 
First a ball-like tumour appears just below the ribs on the left side (see 
Fig. 49). It is usually about one and a half to two inches in diameter 
and slowly moves toward the right and slightly upward. It disappears 
just beyond the median line. It is repeated every minute or two. Some- 
times one wave is quickly followed by another. These gastric contrac- 
tions can hardly be mistaken for anything else. They may be accom- 
panied by slight evidences of pain. 

Tumour. — The hardened pylorus can with careful attention to details 
be felt in most cases. It may be obscured by distention of the stomach 
or the colon or by enlargement of the liver. The pylorus may be dis- 
placed. The position of the tumour is therefore of less importance in 
diagnosis than its character. It is usually felt about one and a half 
to two inches below the free border of the ribs, just inside of the right 



316 DISEASES OF THE DIGESTIVE SYSTEM. 

mammary line. It is felt only during contraction of the stomach, i.e., 
host during active peristalsis. It appears somewhat smaller than the 
little finger and about three-fourths of an inch long, somewhat like a 
small spool. 

Course of the Disease. — Two types of cases are seen: (1) the acute, 
the usual type which, unless relieved by medical or surgical treatment, 
generally proves fatal in one or two months; less 'frequently, and when 
the symptoms are of a milder type, after persisting for several weeks or 
months, the vomiting gradually subsides and the patient recovers; (2) 
the subacute or chronic form, which is very rare, but which may give 
symptoms at irregular intervals during infancy and early childhood. 
The acute cases differ much in severity but little in other respects. The 
chronic cases may show periods of exacerbation for years. These exacer- 
bations are sometimes apparently excited by attacks of indigestion. In 
this type correct diagnosis is seldom made unless operation is done or 
the case comes to autopsy. 

Diagnosis. — The diagnosis of pyloric stenosis of infancy is usually 
easy after two or three days of observation, but may be impossible at the 
first examination, owing to the difficulty of obtaining the most distinctive 
signs — the peristaltic waves and the tumour. The time of onset and 
nature of the vomiting are very suggestive, but not quite conclusive. It 
has been mistaken for cerebral disease on account of the projectile vomit- 
ing and obstinate constipation. In the rare cases seen in older children 
it might be confounded with cyclic vomiting. However, the query arises 
whether some of the cases diagnosticated cyclic vomiting may not be of 
this kind. I have myself seen one such. Usually, however, the only 
difficulty is to distinguish between the vomiting of gastric indigestion 
and that of pyloric stenosis. The occurrence of vomiting in nursing 
infants who have previously thriven on the same food, the abruptness of 
the development of the vomiting without assignable cause, and its per- 
sistence in spite of all treatment, should set one right. Cases in which 
there is atresia of the duodenum or other part of the small intestine 
may be mistaken for pyloric stenosis in which the symptoms begin 
soon after birth. However, in atresia all the symptoms are altogether 
more severe and the condition is usually fatal in a few days. I have seen 
one case of partial obstruction of the duodenum due to pressure by a 
band in which persistent and projectile vomiting and gastric peristalsis 
were present. The vomited matters, however, were green from the pres- 
ence of bile. This does not occur in pyloric stenosis. 

Prognosis. — The condition is always serious, and even with the most 
approved methods of treatment the mortality is large. I believe that 
fully fifty per cent of the cases prove fatal. Much, of course, depends 
upon early diagnosis and proper treatment. Some writers who include 
in the group of pyloric stenosis many cases regarded by them as milder 



HYPERTROPHIC STENOSIS OF THE PYLORUS. 317 

types of the disease, give, of course, a much lower mortality. The 
tighter the obstruction — as indicated by persistence of vomiting in spite 
of stomach washing, stools of a meconium character, and rapid wasting — 
the worse the prognosis. 

Treatment. — Some surgeons argue that, given a correct diagnosis, the 
only rational treatment is operation, all other measures being only a 
waste of time and lessening the chances of surgical success because of 
the weakened condition of the patient. On the other hand, so high is 
the mortality after surgical operation and so great are the difficulties of 
after-treatment, even when the immediate result of the operation is 
favourable, and so many are the undoubted cases which have recovered 
without operation, that most physicians favour a faithful and patient 
trial of other measures before referring the case to the surgeon, and 
recommend operation only as a last resort. One's view of treatment will 
naturally be modified according to the etiological factor he holds to be 
most important. If the obstruction is chiefly from tonic spasm, there is 
no reason why this may not relax and complete recovery take place. If 
the obstruction is chiefly due to congenital hypertrophy with only a mod- 
erate amount of spasm, and this secondary, little that is permanent is 
to be expected by medical means alone. It is my own belief that both 
of these types of cases are seen: the one in which the obstruction is 
nearly all due to spasm, and the other in which the hypertrophy is the 
more important factor. It is certain that many cases have recovered 
completely and permanently without surgical aid. A considerable num- 
ber have come under my own observation. We should, therefore, I 
think, approach these cases with the knowledge that the condition is 
a serious one, that the chances of the patient's recovery are only about 
even under any method of treatment, that there is a fair prospect of cure 
by medical measures alone, but, finally, that some cases can be saved only 
by operation. 

Medical Treatment. — This consists in diet and stomach washing. If 
a child is nursing and the milk is normal, weaning is not generally ad- 
visable. Small meals, not too near together, are essential. The breast 
should be given at three-hour intervals, and the nursing period varied 
from three to eight minutes, according to the amount obtained. It is 
often advantageous to pump the breasts and give a definitely measured 
amount of breast-milk. Usually for a child a month old not more than 
two ounces should be allowed at one feeding. On no account should an 
infant be weaned immediately because of the development of the symp- 
toms of pyloric stenosis. For some infants who have been artificially 
fed nothing succeeds as well as a wet-nurse. The chief objection to the 
breast-milk is its high fat which sometimes increases the vomiting. 

For infants who are artificially fed a few general principles are 
pretty well established. In all milk formulas the fat should be low, 



318 DISEASES OF THE DIGESTIVE SYSTEM. 

usually less than that in whole milk. The formulas from skimmed milk 
have usually, in my experience, succeeded best. The addition of fat 
in the form of olive oil can often be made when the fat of milk is not 
tolerated. Other things besides milk which are sometimes useful are, 
egg albumin and beef juice. Feeding should be regular and not oftener 
than everv three hours, and the amount at one time from one and a half 
to three ounces. 

Xo one thing is better attested than the beneficial effects of stomach 
washing. It empties the organ of food and mucus, and it certainly aids 
in allaying spasm. I prefer the use of water at 108° to 110° F., ren- 
dered alkaline by the addition of one per cent of bicarbonate of soda. 
It is desirable to see how much food there has been retained in the 
stomach; a measured amount of water should therefore be introduced 
and then removed. The washing should be done about two and a half 
hours after feeding, and repeated twice in twenty-four hours. It should 
be continued for a considerable period. In cases which recover it has 
often been found necessary for six to eight weeks twice daily, and for 
three or four months once daily. Hot applications over the epigastrium 
may possibly aid in relaxing spasm, but are of much less value than 
stomach washing. The administration of drugs, especially preparations 
of opium and belladonna, for the same purpose, is advocated by many, 
but in my experience they have been entirely without value. The usual 
effect of stomach washing and changes in diet are a cessation of, or at 
least a great diminution in, the vomiting. But it should not be discon- 
tinued because of this improvement. The loss of weight is less rapid, 
then ceases, and afterward a slow gain occurs; but the condition of the 
patient continues critical for some months. 

Indications for Operative Interference. — In other cases no improve- 
ment whatever results from medical treatment; the vomiting is as 
frequent and as severe as ever; the daily loss in w T eight may be as 
much as two ounces; and the stools indicate that nothing passes the 
pylorus. If such conditions have been observed to exist for several days, 
to postpone surgical interference is useless. The surgical aspects of 
these cases are fully treated in works on surgery. The operations chiefly 
done are gastro-enterostomy and divulsion (Loreta's operation). Each 
has its advocates. The weight of opinion seems now in favour of the 
former operation. The immediate dangers are considerable. Shock is 
generally marked in these little patients, but in my own experience less 
than was expected. Some of these wasted infants of seven or eight 
pounds have gone through an operation which consumed thirty-five min- 
utes in a manner most surprising. Haemorrhages and peritonitis are 
also risks to be reckoned with. The after-treatment is most important, 
and even after a successful operation the dangers are by no means passed, 
the child's life often hangs by a thread for two weeks or more. Exhaus- 



VOMITING. 319 

tion from shock and feeble assimilation, inanition from a continuance 
of the vomiting or the development of diarrhoea, both common symp- 
toms, may carry off the patient. The post-operative treatment should 
be in the hands of the physician rather than the surgeon. To supply fluid 
immediately after operation, nothing is better than the continuous intro- 
duction of water into the bowel by the " Murphy," or " drop method." 
After operation vomiting may sometimes be allayed by placing the child 
in a semi-erect position. Feeding should be begun after twenty-four 
hours with breast-milk if possible, at first in teaspoonful doses, the 
amount being gradually increased according to the child's symptoms. 
The nutrition for the first weeks is nearly always a matter of much diffi- 
culty and taxes the resources of the physician to the utmost. If breast- 
milk can not be obtained, cow's milk should be given, modified accord- 
ing to the child's symptoms, preferably with a rather low fat percentage. 
To keep the child perfectly quiet after feeding is very necessary for a 
long time. Relapses occur in a very small proportion of the cases treated 
by forcible stretching, and I have seen a relapse in a case treated by 
stomach washing and diet, but it is not a common occurrence. 



VOMITING. 

Vomiting is one of the most frequent symptoms of disease in in- 
fants and young children, and occurs from a wide variety of causes. 
The physician must have in mind both its common and its uncommon 
causes. Vomiting takes place with great facility in young infants even 
from slight causes, owing to the position and shape of the stomach. 

1. Vomiting from Overfilling of the Stomach. — This is often seen in 
nursing infants, and there may be no other symptom of disease. It 
eomes within a few minutes after nursing, is easy and without effort, 
and the food is but little changed. It may be excited by moving the 
child or making undue pressure upon the stomach. It often comes with 
eructations of gas or air which has been swallowed. 

Vomiting from overdistention may be regarded as a safety-valve, 
and requires no treatment except to diminish the quantity of food. 

2. Vomiting is almost invariably present in cases of acute gastric in- 
digestion and acute gastritis. With the former it does not usually come 
immediately after feeding, and it may. be delayed for several hours; 
with the latter it is usually persistent. The vomited matter consists of 
the contents of the stomach, but often mucus, and, in severe cases, bile 
and traces of blood may be vomited for some time afterward. 

3. In the hypertrophic stenosis of the pylorus of early infancy, un- 
controllable vomiting without fever is the principal symptom. (See 
previous Chapter.) 

4. In acute intestinal obstruction vomiting is rarely absent, and in 



320 DISEASES OF THE DIGESTIVE SYSTEM. 

most cases it is persistent. In the newly born, persistent vomiting is 
almost invariably dependent upon congenital obstruction of the intes- 
tine, which is most frequently in the duodenum. In malformations of 
the colon and rectum it is less constant and appears later. In intussus- 
ception, vomiting is forcible, immediately excited by the taking of food, 
and is at first bilious, but later may become faecal. 

5. Vomiting is a frequent and almost a constant symptom of acute 
peritonitis, whether localised or general, of which appendicitis is the 
usual cause. It is then associated with abdominal distention, tenderness, 
and fever. 

6. In certain nervous diseases, especially tumour of the brain and 
acute meningitis, whether cerebro-spinal or tuberculous, vomiting is very 
common. Cerebral vomiting is usually forcible or projectile. It may 
have no relation to meals. Headache, dulness, slight fever, constipation, 
and irregular pulse and respiration are usually present sooner or later. 

7. In infants, and less frequently in older children, vomiting is one 
of the most frequent symptoms to mark the onset of acute febrile dis- 
eases, especially the beginning of scarlet fever, pneumonia, and malaria. 

8. An accumulation in the blood of various toxic materials may pro- 
voke vomiting; the best known example is uraemia. In cyclic vomit- 
ing it is quite probable that the cause is the accumulation of some toxic 
substance in the blood. The absorption of poisons taken in with milk 
or other food, or developing in the gastro-enteric tract, may excite vom- 
iting. In some of these conditions it is possible that the vomiting may 
be eliminative. The cases dependent upon renal disease are discovered 
by examination of the urine. The other forms are often exceedingly 
obscure, and recognised only by the exclusion of all other causes of 
vomiting. 

9. Vomiting may be reflex from irritation in the pharynx. This is 
frequent in young infants, who may induce vomiting by stuffing the 
fingers into the mouth. In certain cases the irritation from worms in 
the intestinal tract may cause vomiting, and it is possible that even den- 
tition may produce it. 

10. Habit is a frequent cause, in cases of chronic vomiting. I have 
seen many children who had the power of vomiting at will anything in 
the nature of food which they did not like, yet who would retain other 
food with no difficulty. One such child would tolerate large doses of 
quinine, to which he had no aversion, without the slightest disturbance. 
In young infants a habit of regurgitating the food may be acquired, 
so that this takes place more or less during the process of digestion after 
every meal. This is sometimes preceded by a movement of the mouth 
and fauces resembling swallowing, until finally the milk appears in the 
mouth. Habit is a potent cause in continuing vomiting where it has 
occurred frequently. In children who have this habit the most trivial 



CYCLIC VOMITING. 321 

cause will provoke it. It may be present without any other sign of gas- 
tric disease, and appears simply to depend upon exaggerated reflex 
irritability of the organ. I have seen a number of children who up to 
the third or fourth year objected so strenuously to taking solid food 
that they would immediately vomit it, no matter of what variety or in 
how small a quantity, although fluids were taken and easily digested. 

11. Chronic vomiting may depend upon habit, as just described, or 
upon chronic indigestion; or it may be associated with chronic pulmo- 
nary disease — vomiting here being excited by the attacks of cough, at 
first only when the paroxysms are severe, and later even when they are 
slight. 

The diagnosis of a case in which vomiting is the chief symptom 
may be difficult. The first important distinction to be made is be- 
tween cases in which the vomiting is of gastric origin, and those in 
which it depends upon other causes. It is only by a careful consideration 
of the associated symptoms that an accurate diagnosis can be reached. 

The treatment of vomiting is the treatment of the cause upon which 
it depends. 

CYCLIC VOMITING. 

This is quite a frequent condition; it has, however, attracted but 
little attention except in this country. Although the clinical picture 
is a very clear and definite one, its exact pathology is undetermined. 
It has also been described under the names periodical vomiting and 
recurrent vomiting. It is characterised by periodical attacks of vomit- 
ing, which recur at regular or irregular intervals of weeks or months, 
apparently without any adequate exciting cause. The usual duration 
of the attacks is two or three days, during whick all attempts to control 
the vomiting are usually without avail, but at the end of this time it 
generally ceases spontaneously. 

Etiology. — The first attacks are usually seen between the ages of 
two and four years, but they may date back to infancy. The two sexes 
seem to be almost equally liable. A few of the patients are strong chil- 
dren, but the great majority are rather delicate and of a highly nervous 
temperament. The cases are seen chiefly in private practice, often oc- 
curring among those who have the best surroundings. In most cases the 
antecedents of patients are of a neurotic type. The attacks are not 
usually traceable to distinct or flagrant errors in diet, and yet the habit- 
ual diet seems to bear some relation to the disease. The exciting cause 
is often a nervous one — great fatigue or unusual excitement, sometimes 
a railroad journey or a child's party; in many instances it seems to be 
induced by some minor illness having no relation to the digestive tract, 
such as an attack of tonsillitis or bronchitis. In children subject to this 
condition serious diseases, such as scarlet fever or measles, may be ushered 
22 



322 DISEASES OF THE DIGESTIVE SYSTEM. 

in by prolonged and repeated vomiting, which usually ceases before the 
end of the febrile period. General anaesthesia, especially by ether, is very 
likely to precipitate an attack. 

Symptoms. — The clinical picture presented by these cases is very 
characteristic; and is well illustrated by the history of the following 
case : 

The patient was a well-nourished boy of six years when he first came 
under treatment. He belonged to a neurotic family, and the attacks 
dated back to infancy. From this time they had recurred usually at in- 
tervals of a few months ; occasionally five or six months would pass with- 
out one. The symptoms in all the attacks were similar in kind, differ- 
ing only in degree. They were preceded by a prodromal period lasting 
from twelve to twenty-four hours, marked by languor, dulness, dark 
rings under the eyes, loss of appetite, and a general sense of discomfort 
in the epigastrium. At this time the temperature was generally slightly 
elevated. The vomiting then began suddenly. It was attended with 
great retching and distress; it was often repeated every half -hour or 
hour for two days. On one occasion it occurred seventeen times in a 
single night. Vomiting was immediately excited by the taking of any 
food or drink, but it occurred when nothing was taken. The vomited 
matters consisted of frothy mucus and serum, frequently streaked with 
blood, apparently from the violence of the emesis, and often containing 
bile. The temperature usually fell to about 100° F. when the vomiting 
began, and continued at or below this point throughout the attack. By 
the end of the second day the exhaustion was very marked — so severe, in 
fact, as apparently to threaten life. 

The child lay in a semi-stupor, with eyes half open, lips and tongue 
dry, rousing at times to beg for water. The pulse was rapid and weak, 
and sometimes slightly irregular. There was no distention of the abdo- 
men; it was usually flattened. By the third day the vomiting became 
less frequent and then ceased entirely. Convalescence was rapid, and 
by the end of the week the boy was almost as well as usual. The attacks 
continued to recur at gradually lengthening intervals until the)*- finally 
ceased altogether at about the twelfth year. 

A great number of these cases have come under my observation, and 
in many patients I have had an opportunity to witness several attacks. 
The usual duration is one to three days. In one child they lasted regu- 
larly for five days. Occasionally a severe attack will last a week. The 
average number of attacks is three or four a year. 

Prodromal symptoms are present in most of them — headache, gen- 
eral languor, coated tongue, and anorexia are the most frequent; in 
some there is marked constipation, with a history of very white stools 
for some time. But it is not uncommon for an attack to occur in the 
midst of apparently perfect health. The tongue is usually coated at the 



CYCLIC VOMITING. 323 

beginning of an attack, and at its height it is often dry and brown. The 
abdomen seems empty and its walls sunken; pain and tenderness are 
both rare. The bowels are usually constipated and move only with diffi- 
culty by artificial means. Very exceptionally there may be diarrhoea 
with foul stools. 

There is, as a rule, no desire for food, but the continual cry is 
for water to quench the constant, burning thirst. The pulse after the 
second day becomes rapid, soft, and often somewhat irregular. The 
respiration is shallow, and at times this also may be irregular. The 
temperature is usually under 100.5° F., rarely it may be 102° or 103° F. 
The usual low temperature is a point of much diagnostic value. The 
patients are dull, apathetic, and usually wish to be left alone. Head- 
ache is very common. 

The disposition to vomit is sometimes so great that patients are 
afraid to move or even to talk lest it may be provoked. The vomited 
matter is often large in amount, considering that the patient is fasting. 
It is essentially gastric juice, containing free HC1, mucus, serum, many 
epithelial cells, and often traces of blood. Less frequently vomiting may 
occur only two or three times a day. The urine is concentrated, and 
frequently contains at the height of the attack a trace of albumin, a few 
hyaline casts, and some blood cells. An increase in the renal secretion 
may be the first sign of improvement. There is usually an excess of 
indican both during and between attacks. A condition practically con- 
stant, and first pointed out by Edsall, is the presence in the urine of 
acetone, diacetic and oxybutyric acids. These substances appear in the 
urine so early in the attack that they can not be ascribed to starvation, 
and are therefore of much diagnostic value. 

The Nature of the Attacks. — These cases have little in common with 
the ordinary attacks of indigestion. With our present knowledge they 
are to be regarded as explosions due to faulty metabolism, and there 
are many reasons for the opinion that the vomiting is an effort at 
elimination. It is probable that not all the cases depend upon the 
same condition. 

Prognosis. — Although these patients very often seem to be most 
alarmingly ill, the danger to life is slight. I have seen but one fatal 
case, and in this the diagnosis is open to question, as no autopsy could 
be obtained. Griffith reports two fatal cases, the autopsy in one showing 
nothing characteristic. The probabilities are always in favour of a recur- 
rence of the attacks. In most of the patients who have been observed 
they have extended over a series of several years, although by a careful 
regime much may be done to reduce their frequency and diminish their 
severity. In a small proportion of cases they may be stopped altogether. 
Toward puberty there appears to be a strong tendency to spontaneous 
recovery. 



324 DISEASES OF THE DIGESTIVE SYSTEM. 

Diagnosis. — Organic disease of the brain and kidneys must first be 
excluded. The first attacks witnessed may strongly suggest the onset of 
tuberculous meningitis ; and only the course of the symptoms may show 
that this is not present. Usually a history of many previous attacks 
may be obtained. From acute indigestion, cyclic vomiting is differen- 
tiated by the fact that the attacks are not brought on by indigestible 
food, and also by the persistence of the vomiting, and the early presence 
in the urine of the acetone bodies. It is distinguished from gastritis by 
its severity, the shorter duration of its symptoms, and its self-limited 
course. 

Appendicitis is excluded by the absence of pain, tenderness, and mus- 
cular rigidity; intussusception by the fact that the symptoms are less 
severe, by the absence of blood and mucus from the stools, and by the 
fact that intussusception is usually seen in infancy. 

Treatment. — When the premonitory symptoms appear, starvation 
and free purgation offer the best prospect of aborting an attack. If 
the vomiting has once begun, nothing seems to have the slightest influ- 
ence in controlling it. It is usually increased by the taking of food or 
drink or by any medication by the mouth, and all should be withheld. 
The patient should be kept absolutely quiet and water given, per rectum, 
at regular intervals, usually six to eight ounces, four or five times a day. 
This keeps up the urinary secretion, allays thirst and often restlessness, 
and when it is retained usually adds much to the patient's comfort. 
When the vomiting has ceased for several hours it is not likely to recur 
if food is very judiciously administered, at first in small quantities. 
Broth, barley water, kumyss, or small quantities of iced milk and lime- 
water in equal proportions may then be given. 

The alkaline treatment has been strongly advocated; it consists 
in giving between the attacks bicarbonate of soda in doses of fifteen 
to thirty grains three times daily, and, when the prodromal signs of 
an attack appear, to administer very large doses, as much as thirty 
grains every hour. I have used this plan of treatment with some appar- 
ent success and think it deserves a trial. In the interval the treatment 
should be chiefly dietetic. All sugar and sweets should be carefully ex- 
cluded. The diet should consist principally of meat, green vegetables, 
milk, cereals in moderate amount, and stale bread. In addition to care- 
ful regulation of the diet the general nutrition should be considered, 
and the patient's life so regulated that extreme fatigue and exhaustion 
are prevented. In most cases close attention to these matters has re- 
sulted in a very great diminution in the frequency of the attacks. 

GASTRALGIA. 

This term is applied to sudden, severe attacks of abdominal pain. 
Oastralgia occurs as a symptom in most of the severe attacks of acute 



ACUTE GASTRIC INDIGESTION. 325 

gastric indigestion; in such cases it is more marked in older children 
than in infancy. The pain of diaphragmatic pleurisy is often referred 
to the epigastrium, and may be so severe as to lead one to think that 
the stomach is the seat of disease. Another cause may be appendicitis. 
In vertebral caries of the dorsal region epigastric pain is a very frequent, 
early symptom. It is also common in children who suffer from malaria 
at the onset of acute attacks, and it may be severe when the febrile symp- 
toms are not well marked. In other cases pain in the stomach is of the 
nature of a true neuralgia, which may be excited by exposure to cold, 
by wetting the feet, by drinking ice-water, and by many other causes. 

In mild cases there is an intermittent pain, and usually no other 
symptoms. In severe cases the pain may be so great as to cause pallor, 
faintness, cold perspiration, and very marked prostration. The epigas- 
trium may be hard and sometimes retracted, the stomach appearing to 
be in a state of spasm. 

The principal interest attaches to diagnosis. If the pain is acute, one 
should carefully exclude appendicitis, renal and hepatic colic, ulcer with 
perforation, and all acute inflammatory conditions in the abdomen; if 
more chronic, Pott's disease should not be forgotten. 

During the attacks the patient should be put to bed, and counter- 
irritation used over the stomach, best by means of a turpentine stupe or 
a mustard paste. Internally there should be given hot water containing 
a few drops of brandy or gin and five drops of spirits of chloroform; all 
food should be withheld. Hot bottles should be applied to the feet if 
they are cold. In the interval between the attacks the treatment should 
be directed to the patient's general condition ; especially should the cause 
be discovered, and if possible removed. In cases of recurring pain of a 
neuralgic character arsenic in the form of Fowler's solution, one or two 
drops three times a day, may prove of benefit. In all cases attention 
should be directed to the diet. 



ACUTE GASTRIC INDIGESTION. 

This occurs whenever the stomach is unequal to the task imposed 
upon it. It may be either because the task is too great or because the 
capacity of the stomach for work is diminished. Under these two heads 
we may group the principal causes of acute indigestion. 

Under the first head the most important thing is the giving of im- 
proper food. In infants this is sometimes improper breast-milk; but 
more often cow's milk containing too high fat. Other common causes 
are sudden weaning or any other abrupt change in diet, the too early 
use of solid food, and overloading the stomach. In older children the 
usual causes are indigestible articles of food, such as unripe fruits, 
pastry, imperfectly cooked cereals, etc., overloading the stomach, and 



326 DISEASES OF THE DIGESTIVE SYSTEM. 

swallowing food without sufficiently masticating it. Conditions whi'ch 
may diminish for the time the capacity of the stomach for work are 
fatigue, depression induced by atmospheric heat, chilling of the surface, 
especially the extremities, dentition, and the nervous impression caused 
by the onset of any acute disease. The effect is seen both on the 
glandular and muscular apparatus of the stomach. The secretions are 
diminished or altered in character, and the motility of the organ is 
arrested. 

Symptoms. — One of the first consequences of arrested gastric diges- 
tion is that the food remains long in the stomach. Instead of the stom- 
ach's being empty in about three hours after feeding, as is normal in in- 
fancy, the food may remain in it five or six hours, or even longer. The 
irritation from this undigested and fermenting mass excites vomiting, 
which usually ceases after the stomach has been emptied. The vomiting 
may be preceded by nausea, pain, and constitutional depression which 
varies with the age and susceptibility of the child; in infants it may be 
very alarming. 

The nervous symptoms are sometimes of a striking character. There 
may be dulness, stupor, and sometimes contracted pupils, so as to sug- 
gest opium narcosis, or there may be restlessness, and even convulsions. 
There is also marked prostration and fever. The temperature in most 
cases of acute indigestion is from 101° to 103° F. ; not infrequently it 
rises to 104° or 105° F. The tongue is coated and the appetite entirely 
lost. In infants these symptoms are usually associated with or followed 
by more or less intestinal disturbance — generally diarrhoea, with un- 
digested food in the stools. Epigastric distention may be present. 
Usually the vomiting ceases in from six to twelve hours and after the 
stomach has been thoroughly emptied the temperature falls. Provided 
rest to the organ can be secured, and the exciting cause is one that can 
be removed, the patient may be quite well in two or three days. Eelapses 
are, however, easily excited ; and in a susceptible patient it is surprising 
to see how trivial a cause may excite one. 

The diagnosis between a simple attack of acute indigestion and one of 
gastritis can not be made at the outset. The former is much more fre- 
quent, and may be quite as severe, but is of shorter duration. The 
prognosis in these cases is good, except in very young or very delicate 
infants. 

Treatment. — The indications are, to empty the stomach as com- 
pletely as possible and then to secure for it absolute rest. If proper 
treatment is employed at the outset, the majority of such attacks can 
be cut short. Nothing is so efficient in infants as stomach-washing. A 
single washing usually suffices. If for any reason this can not be em- 
ployed, the child may take from its bottle a large amount of lukewarm 
water. The free vomiting which this usually provokes may be sufficient 



ACUTE GASTRITIS. 327 

to cleanse the stomach fairly well, but by no means so thoroughly as 
stomach-washing. Persistent vomiting is sometimes arrested by giving 
small quantities of hot water. 

The subsequent treatment is chiefly dietetic. Everything should be 
withheld for six to eight hours, when thin barley water or albumin 
water may be given in small quantities, e. g., half an ounce to one 
ounce every hour. After twenty-four hours beef juice or broth may be 
added, but no milk should be given for two or three days. When begun, 
it should be skimmed and diluted with five or six parts of water. In a 
nursing child, the breast should be withheld altogether for twenty-four 
hours, and then nursing allowed for two minutes every three hours, 
the time of nursing being gradually increased to three, five, and ten 
minutes as improvement occurs. The great mistake made in these cases 
is to begin food too soon and to give too much, especially of cow's 
milk. 

Drugs are relatively of little value. If the measures mentioned have 
been used promptly they will not often be required. In many cases inju- 
dicious medication aggravates the symptoms and prolongs the attack. 
Unless the bowels have acted freely, calomel (gr. -J every hour) may be 
given until this effect is obtained. Where there is continuous vomiting 
of very acid mucus and serum, alkalies are indicated — lime-water, chalk 
mixture, or the subcarbonate of bismuth. It is important to keep the 
child as quiet as possible. Local applications to the epigastrium are very 
often useful. Either dry heat may be applied by means of a hot-water 
bag or hot flannels, or more active counter-irritation by mustard. In 
older children the stomach should be kept entirely at rest for half a day, 
only carbonated waters or barley water being allowed in small quantities 
to allay thirst. Later, broth or beef juice may be given, afterward 
skimmed milk diluted with lime-water. The patient should be kept 
upon a very low diet for four or five days. 



ACUTE GASTRITIS. 

In comparison with the frequency of inflammatory diseases of the 
intestine, those of the stomach are rare, particularly so in infancy. 
Owing largely to the character of its secretion and its contents, the stom- 
ach is much more resistant to infection than are the intestines. Gastritis 
seldom exists alone, but is usually associated with enteritis or colitis. 

Etiology. — The causes of gastritis are, in the main, those of acute 
gastric indigestion — improper food or feeding — to which possibly is 
added infection. Gastritis may also be caused by the introduction of 
irritants, which may either be swallowed accidentally or given as drugs. 

Lesions. — The mucous membrane of the stomach may be the seat of 
acute catarrhal, ulcerative, or membranous inflammation, all forms ex- 



328 DISEASES OF THE DIGESTIVE SYSTEM. 

cepi the catarrhal being rare. There is also seen a mixed form, which 
from its cause is usually termed " corrosive gastritis." 

Catarrhal Gastritis. — This is characterised by hyperemia of the mu- 
cous membrane, exudation of cells into the mucosa, a great increase 
in the secretion of the mucous glands, and changes in the epithelium. 
About the only change which can he recognised by the naked eye is 
congestion and swelling of the mucous membrane. These are usually 
more marked toward the pyloric end and along the greater curvature. 
There may be small extravasations of blood into the mucosa. The stom- 
ach contains undigested food and mucus, which may be thick and tena- 
cious, adhering very closely to the mucous membrane. The mucus may 
be stained brown from the capillary haemorrhages. The stomach may be 
either distended or contracted. Under the microscope the changes are 
seen to be almost entirely in the mucosa. In some places there is loss of 
the superficial epithelium, in others only degenerative changes in it are 
seen. The mucosa is infiltrated with round cells, this process being 
rarely diffuse, but generally occurring in patches. The blood-vessels are 
distended and many small extravasations are seen. Sometimes there is 
a moderate infiltration of the submucosa. Acute catarrhal gastritis 
alone is rarely severe enough to cause death. It is usually seen in cases 
which prove fatal from other causes, particularly diseases of the intestine. 

Gastric softening (g 'astro mat acid) is a condition dependent upon 
post-mortem changes — probably self-digestion of the stomach. It is 
found both where gastric symptoms were present and where they were 
absent. It is situated nearly always in the posterior wall, and usually 
covers a considerable area, about one-third or one-fourth of this wall. It 
is recognised by the gelatinous, translucent appearance of the walls of 
the stomach, which are so softened that the finger may be pushed through 
them without force, or that sometimes the stomach ruptures while it is 
being removed. This condition is rarely seen when the stomach is empty. 
It can scarcely be mistaken for a pathological condition, if its occurrence 
is borne in mind. 

Ulcerative Gastritis. — This was met with six times, not including 
tuberculous cases, in 390 consecutive autopsies upon infants in the 
Babies' Hospital. Three of the patients were less than four months old, 
and all were females. The ulcers varied from one twenty-fifth to one 
quarter of an inch in diameter, and usually from ten to fifty were pres- 
ent. They seldom extended to the muscular, and never to the peritoneal 
coat. The lesion was most marked in the posterior wall, toward the 
pyloric end and along the greater curvature. Evidences of catarrhal in- 
flammation were present in most of the cases, and in four, of mem- 
branous inflammation. Lesions in some other part of the digestive tract 
were present in all but one case, in two there was thrush in the oesopha- 
gus ; in three there was ulceration somewhere in the intestines. 



ACUTE GASTRITIS. 329 

Membranous Gastritis. — This is even more rare than the varieties 
previously mentioned. I have met with it but four times in infants. 
One case was associated with a membranous colitis; a second case with 
a streptococcus inflammation of the fauces and larynx in an infant but six 
weeks old. The oesophagus was not involved in this case; and indeed it 
often escapes. No Klebs-Loeffler bacilli could be found either in cover- 
slip preparations or by culture. 

To the naked eye the membrane appears of a grayish-green colour; 
it is adherent, but can be detached in quite large patches. • Only a por- 
tion of the stomach was covered in any of the cases ; in two the principal 
disease was about the pylorus; in another along the greater curvature. 
The microscopical appearances resemble those of membranous colitis. 
There is a pseudo-membrane composed of fibrin, granular matter, epi- 
thelial cells, and bacteria. The mucosa shows a moderately dense infil- 
tration with round cells, and in places superficial ulceration. There is 
also infiltration of the submucosa, and in some places even the muscular' 
coat is involved. 

Membranous gastritis occurring in patients dying of diphtheria is 
not common. Councilman, Mallory, and Pearce noted its presence in 
only five of one hundred and twenty-seven autopsies. 

Corrosive Gastritis (toxic gastritis). — This form of inflammation is 
excited by various irritating and caustic substances, which are usually 
taken by accident, sometimes for the purpose of producing emesis. The 
most frequent substances are carbolic acid and caustic alkalies. 

The lesions in the stomach depend upon the amount of the substance 
swallowed, the degree of concentration, and whether the stomach was 
full or empty at the time. Strong caustics, whether acids or alkalies, 
usually act more deeply and extensively in the pharynx and oesophagus, 
for, owing to the spasmodic contraction of the muscles of these parts, 
often but a small amount of the substance reaches the stomach. Concen- 
trated irritant poisons produce in the stomach, especially along the 
greater curvature, irregular ulcers, which may be so deep as to cause per- 
foration, or they may affect the mucous membrane only. In severe cases 
death takes place early, often in a few hours. Dark, ragged ulcers are 
found in the stomach, the surrounding mucous membrane is the seat of 
intense congestion, and in places there are extravasations of blood. If 
death is delayed there are evidences of intense inflammation, sometimes 
with the production of a pseudo-membrane. If the amount of poison is 
not sufficient to cause death, and if the patient recovers from the result- 
ing gastritis, a cicatricial condition of the stomach results, which later 
may lead to stenosis of the p3 r lorus or other deformity of the organ. 

Symptoms. — Catarrhal gastritis can not be distinguished at its begin- 
ning from an attack of acute indigestion. There are fever, pain, vomit- 
ing, thirst, loss of appetite, coated tongue, and prostration. The pres- 



330 DISEASES OF THE DIGESTIVE SYSTEM. 

ence of inflammatory changes is indicated by the continuance of these 
symptoms, particularly the pain, vomiting, fever, and thirst. With the 
pain there may be epigastric tenderness. All food and liquids are im- 
mediately rejected, and even when nothing is taken the retching and 
vomiting may continue, nothing but frothy mucus or serum being 
brought up, sometimes streaked with blood. The vomited matters are 
usually very sour; they may be bilious. The temperature is rarely high 
except at the outset. After the first or second day it usually ranges 
between 100° and 101.5° F. Thirst is intense, and all liquids are taken 
with avidity, especially if cold, even though they are immediately 
vomited. The tongue is thickly coated with a white fur, and the breath 
may be foul. The constitutional symptoms are generally most severe at 
the outset. The usual duration of such attacks is from four to seven 
days, but with improper management, especially injudicious feeding, 
the disease may be much prolonged. One attack may follow another 
until a chronic condition is established. In most of the cases there is 
some disturbance of the intestines, usually a sharp attack of diarrhoea. 
Sometimes the gastric symptoms subside after a few days and those of 
the intestines become the predominant ones. The symptoms above given 
are those in infancy. In older children there is less fever, prostration, 
and diarrhoea, but pain and vomiting are prominent. The attacks are 
usually shorter and altogether less severe. 

The rare cases of ulcerative gastritis have nothing by which they 
can be distinguished from the form described, except a more prolonged 
course and a greater liability to haemorrhage. 

Membranous gastritis also presents no peculiar symptoms. In fact, 
in the cases I have personally seen, the gastric symptoms were insig- 
nificant, and the condition not suspected during life. 

In corrosive gastritis the effects of the caustic may be seen in the 
mouth and pharynx, the mucous membrane being usually of a gray or 
whitish colour. Pain and a sense of constriction are felt in the oesophagus 
and stomach, and thirst is great. Vomiting follows almost immediately, 
and the matters vomited are usually bloody. The subsequent course in 
most of the cases is the rapid development of collapse, and death in a 
few hours from shock. The younger the child the sooner does the case 
terminate. In irritant poisoning not severe enough to produce death, 
the symptoms of acute gastritis follow, usually accompanied by more or 
less enteritis owing to the passage of the irritant into the intestine. 
There is seen a continuance of the vomiting, pain and epigastric disten- 
tion, and diarrhoea, and from these symptoms death may result in two 
or three days. It is extremely rare in infancy for the patient to survive 
both the stage of shock and that of acute inflammation, so that the 
deformities of the stomach and the chronic conditions mentioned are 
practically never met with excepting in older children. 



CHRONIC GASTRIC INDIGESTION. 331 

Treatment. — Cases of acute catarrhal gastritis are to be managed 
very much like those of acute gastric indigestion. Thirst may be re- 
lieved by swallowing bits of ice. Where there is continuous vomiting of 
acid mucus, relief is sometimes afforded by repeating the stomach-wash- 
ing once in twelve hours with a one-per-cent solution of bicarbonate of 
soda, at 110° F. In older children, beneficial results sometimes follow 
the use of bismuth subcarbonate (gr. x every two hours) ; but in infants 
I have seen but little effect from any form of medication, the reliance 
being upon rest, careful feeding, and stomach-washing. 

Cases of corrosive gastritis require special treatment. The first indi- 
cation is to administer the proper chemical antidote to the substance 
swallowed, and the next to use bland mucilaginous or oily fluids, such 
as milk, albumin water, oils in large quantities, etc. Especially should 
stomach-washing be avoided. Opium is always required, on account of 
pain, and should be given hypodermically. The general symptoms are 
to be treated according to the indications of the individual case. 

CHRONIC GASTRIC INDIGESTION— CHRONIC GASTRITIS— GASTRIC 

CATARRH. 

Although from a pathological point of view these conditions may not 
be identical, from a clinical standpoint there is no advantage in attempt- 
ing to separate them. Nothing distinguishes chronic indigestion from 
chronic gastritis except that in the latter, in addition to continued de- 
rangement of function, there is a greater increase in the production of 
gastric mucus. Chronic indigestion does not long exist without the 
production of a certain amount of catarrhal inflammation. This con- 
dition in the stomach seldom, if ever, exists without more or less involve- 
ment of the intestine, and in the majority of cases the intestinal condi- 
tion is the more important. In some, however, the gastric symptoms 
predominate, and it is only those which are here considered. 

Etiology. — Chronic gastric indigestion may follow acute attacks, -or 
it may be chronic from the outset. If the latter, it depends in infancy 
upon the continued use of improper food or bad methods of feeding. 
The improper food is very often a modified cow's milk of improper pro- 
portions. The most frequent mistake is the use of too high a percentage 
of fat. Less frequently the cause is the sugar, especially the use of foods 
containing much cane sugar or maltose. Other factors of importance 
are overfeeding, too large meals, unsuitable food, especially solid food 
for infants. The condition generally accompanies dilatation of the 
stomach. As a consequence of imperfect digestion, fermentation in the 
residuum takes place, and the irritating products of this fermentation 
soon cause a catarrhal inflammation with a production of mucus. Chronic 
gastric indigestion also complicates most of the constitutional diseases 
of infancy, especially rickets, syphilis, tuberculosis, malnutrition, and 



332 DISEASE? OF THE DIGESTIVE SYSTEM. 

marasmus. It may follow any of the acute infectious diseases. In older 
children it is due chiefly to the use of improper food, sometimes to the 
habH o( rapid eating and insufficient mastication, the cause of which is 
vow often carious tooth. It is associated with constitutional diseases as 
in infancy, and may complicate valvular disease of the heart. 

Lesions. — The changes found in chronic gastritis are usually confined 
to the mucosa. In the mild form there are degenerative changes of the 
epithelium of the tubules, with an increased production of mucus; there 
may be a slight infiltration of the mucosa with round cells. The more 
severe form, with marked cell infiltration and the production of new 
connective tissue, is extremely rare. The submucous coat may be thick- 
ened and the muscular coat attenuated. The lesion can not be recognised 
by the naked eye. The stomach is apt to be more or less dilated, and its 
surface is coated with thick and very adherent mucus. This lesion rarely 
exists alone, practically never in infancy, but is associated with similar 
lesions in the intestines, the latter often being more severe. 

Symptoms. — In Infants. — For our knowledge of the conditions ex- 
isting in the stomach in chronic indigestion we are indebted to the work 
chiefly of Cassel, Leo, Troitzky, Wohlmann, and Clarke. The results 
obtained in the examination of stomach contents have not been uniform, 
and in practice one should not lay much stress upon the absence of the 
normal secretions. The presence of mucus in the vomited matters or 
in the washings from the stomach is a constant feature. This greatly 
interferes with digestion, even though secretions are normal. The re- 
action of the stomach is almost invariably acid, but the acidity may be 
due more to the products of fermentation than to hydrochloric acid. The 
latter is almost invariably diminished in quantity and is sometimes ab- 
sent. Free hydrochloric acid is very seldom present. The rennet fer- 
ment and pepsin are usually present in normal amount. Fermentation 
takes place in the fats and the carbohydrates. The results of fermenta- 
tion are the production of lactic, acetic, butyric, and other volatile fatty 
acids, which are especially irritating to the mucous membrane. There 
is an increased production of gas. Food remains long in the stomach 
because of motor inactivity, which is partly the cause and partly the 
result of the disease. It often continues after all other symptoms have 
disappeared. 

The most important local symptom is vomiting. It may occur soon 
or long after feeding. It is often accompanied by frequent regurgitation 
of small amounts of food, which may begin soon after one feeding and 
continue quite to the time for the next, In nearly all protracted cases 
the vomited matters contain mucus, and sometimes this is a conspicuous 
feature. The regurgitation of a sour irritating fluid occurs even when 
but little food is rejected, and usually accompanies the belching of gas. 
In infants some of the most striking symptoms are due to the gas. The 



CHRONIC GASTRIC INDIGESTION. 333 

stomach may be distended and hard most of the time, and often so much 
gas is present that infants find difficulty in taking food. Though 
evidently hungry, they can take so little at a time that an hour or more 
may be required to take four or five ounces. That the food remains 
long in the stomach is best demonstrated by stomach-washing. Instead 
of the stomach's being empty in two and a half or three hours, as it should 
be, food may be found four or five hours, and in some cases six or eight 
hours, after feeding. There may be dilatation of the stomach, especially 
in rachitic children. 

The appetite may be abnormally great, or it may be poor. As a 
rule, children take less food than in health. The tongue is usually 
coated. The general symptoms are those of malnutrition; there is con- 
stant fretfulness and sleep is irregular or disturbed; the weight is sta- 
tionary, or there is steady loss; there is also anaemia, and the child's 
development is arrested. There is nearly always some derangement of 
the bowels, more often constipation than diarrhoea. 

There is little tendency to spontaneous improvement or recovery, the 
prognosis depending almost entirely upon the treatment employed. Un- 
less relieved the condition is apt to continue, until some serious acute 
disease develops which may be fatal. In young infants, chronic gastric 
indigestion should not be confounded with hypertrophic stenosis of the 
pylorus. 

In Older Children. — The disease is not so common as in infants. In 
all cases the most constant symptom is vomiting, which may occur reg- 
ularly after meals, or only in the morning before breakfast. If the latter, 
the vomited matters consist chiefly of mucus. In addition to these reg- 
ular attacks there may be the frequent regurgitation of small quantities 
of food. There are gastric flatulence and pain, due to hyperacidity or 
to acid fermentation. The appetite is variable — sometimes inordinate, 
sometimes entirely lost; it may be capricious, there being usually a 
craving for highly seasoned food. The tongue is constantly furred, and 
the breath usually disagreeable. These symptoms are seen in all degrees 
of severity. Intestinal disturbances are not so frequent as in infancy. 
Constipation is more common than diarrhoea. The general symptoms are 
those of malnutrition. There are anaemia, wasting, constant fretfulness, 
disturbed sleep, and various other nervous disorders. 

Prognosis. — The prognosis depends upon the age of the patient, the 
duration of the disease, the surroundings, and upon how well treatment 
can be carried out. In infants under three months the prognosis as to 
life is doubtful. If children live to the age of four or five months, they 
usually recover with proper treatment. These patients do much better 
in private practice than in institutions. The principal danger from this 
condition consists in the predisposition it gives to acute diarrhceal dis- 
eases in summer. 



334 DISEASES OF THE DIGESTIVE SYSTEM. 

In older children, as in the case of infants, these symptoms may con- 
tinue indefinitely; there is little tendency to spontaneous recovery, but 
under favourable circumstances, with constant care, much may be done 
for all these patients and many of them may be completely cured. 

Treatment. — Infants. — The general treatment is too apt to be ig- 
nored, but it is just as important as measures directed more specifically 
to the stomach. A large, roomy nursery, and plenty of fresh air by night 
and by day, are very important ; equally necessary are quiet surroundings 
and freedom from disturbing conditions which sometimes obtain in the 
nursery; sometimes under the influence of these alone improvement 
begins. General friction of the body is useful in delicate children with 
poor circulation. Infants must be properly covered, and it is of the 
utmost importance that the feet be kept warm. Of the measures directed 
to the stomach, two are chiefly to be depended upon — stomach-washing 
and proper feeding. 

Stomach-washing is useful, first, in removing the mucus which is 
abundant in most of these cases; secondly, in cleansing the organ thor- 
oughly at least once a day, this of itself being most important; thirdly, 
as a stimulant to the gastric secretions, especially hydrochloric acid. 
Plain boiled water, or a weak alkaline solution — sodium bicarbonate, one 
drachm to the pint — may be employed. In the early part of the treat- 
ment the washing should be done daily ; later, every second or third day. 
The time selected is not very important, but it is better to make this 
about three hours after feeding. 

The question of diet has been quite fully discussed in the chapter 
on Infant- Feeding, particularly in the pages in which the feeding in 
difficult cases is considered. If milk is being given, one should first 
endeavour to determine which of the elements is the chief cause of the 
trouble. This is most frequently the fat, and next the sugar. 

The quantity of food and the frequency of feeding are both matters 
of importance. With a serious amount of chronic gastric disturbance 
in infants over three months old the interval between feedings should 
not be less than three hours; many do better when the interval is four 
hours. Small meals of a somewhat concentrated food are usually better 
than large feedings of a very dilute food. Careful study of the indi- 
vidual child is indispensable to success. 

Drugs have a very limited application in the treatment of this condi- 
tion in infants. Generally they are too much used, and too little attention 
is given to the details of feeding, by which means alone permanent im- 
provement is reached. The continued use of pepsin and other digestive 
ferments is irrational and without benefit. Hydrochloric a-cid, however, 
may at times prove of considerable value, but it must be given in rather 
large doses, i. e., five to fifteen drops of the dilute acid after each feed- 
ing. But for the relief of one condition drugs may be of considerable 



DILATATION OF THE STOMACH. 335 

advantage: wherever the production of gas and constant eructations are 
prominent symptoms, the benzoate of soda is sometimes useful. It may 
be given with the feedings in doses of two or three grains. 

Older Children. — The management of these cases in older children 
must be conducted along the lines laid down for infants. With them, 
stomach-washing can not be easily employed, and other means must be 
used to clear the stomach of mucus. The best is undoubtedly the use 
of large draughts of water, as hot as can be borne, an hour before eat- 
ing. From six to eight ounces should be taken, preferably slowly by 
sipping. To this may be advantageously added, in many cases, fifteen or 
twenty grains of bicarbonate of soda. 

The diet should consist of skimmed milk diluted at least once, kumyss 
or matzoon, beef juice, rare meat, and a moderate amount of starchy 
food, preferably dried bread or zwieback. All fruits should be avoided. 
All pastry, sweets, nuts, and candies should be absolutely prohibited. 
With improvement in the symptoms green vegetables may be added to 
the diet, and the amount of starchy food increased. The amount of 
water taken at meal-time should be carefully restricted. Beneficial re- 
sults are often obtained in these cases by the use of nux vomica or sim- 
ple bitters before meals, and the regular administration of hydrochloric 
acid (gtt. v to viij of the dilute acid) shortly after meals. The general 
treatment must not be neglected. The patient should lead an out-of- 
door life as much as possible, and should take regular but very moderate 
exercise. Great caution is necessary against overfatigue. Iron may be 
given in most cases during convalescence; but cod-liver oil should be 
carefully avoided until the gastric symptoms have quite disappeared. 
Relapses are easily excited, and the most constant care regarding the food 
must be maintained for months, or even years. 

DILATATION OF THE STOMACH. 

Moderate dilatation of the stomach is quite a frequent condition, 
although it is not so large a factor in the disorders of digestion in 
infancy and childhood as many who have written upon the subject 
would lead us to believe. A very marked degree of dilatation is rare, 
but in these cases its recognition is important and its treatment difficult. 

Dilatation is almost invariably regular or cylindrical; it is usually 
most marked at the cardiac extremity. Cases of irregular or saccular 
dilatation, except when associated with cicatricial conditions, are of 
somewhat doubtful occurrence. The irregular shapes of the stomach 
found at autopsy dependent upon the contraction of the muscular coats, 
may be easily mistaken for hour-glass contraction or saccular dilatation. 

Dilatation may also result from congenital stenosis of the pylorus. 
The most important predisposing cause, however, is the muscular atony 
which accompanies rickets. It is found to a slight degree in almost all 



336 DISEASES OF THE DIGESTIVE SYSTEM. 

severe eases of rickets. The principal exciting causes are continued 
distention from overfeeding and chronic indigestion. 

Tn most eases the only symptoms are those of the chronic indigestion 
which almost invariably accompanies dilatation. The vomiting seen 
with dilatation is peculiar in that it is infrequent, possibly only once a 
day ; but then the quantity vomited is larger than the last meal taken. 
In young infants the pressure symptoms resulting from acute dilatation 
may be very serious. This is particularly true of those with acute bron- 
chitis or broncho-pneumonia, or atelectasis. In such patients I have seen 
very grave symptoms accompany the rapid distention of a dilated stom- 
ach, and in one very delicate infant of three months this was appar- 
ently the cause of death. A positive diagnosis of dilatation is only 
made by the physical signs. There is epigastric fulness and distention, 
and in some thin patients the outline of the stomach can be distinctly 
seen. Dilatation of the transverse colon, however, may be mistaken for 
dilatation of the stomach. In the latter, the lower outline is convex, 
while in the former it is usually slightly concave. The most satisfactory 
means of diagnosis is by percussion. The examination should be made 
three or four hours after feeding, at which time the whole abdomen is 
apt to be tympanitic. The stomach should then be filled with water; 
the lower limit of the area of flatness will be the lower border of the 
stomach. This is much more satisfactory than determining the outline 
after the generation of gas in the stomach. If the lower border comes 
below the umbilicus, it is dilated. 

In moderate dilatation of the stomach the prognosis is good unless 
due to pyloric stenosis. If the infant has any acute or chronic pulmo- 
nary disease, dilatation of the stomach may add to the discomfort and 
even to the danger from that condition. The distention of a dilated 
stomach occurring in the course of any acute pulmonary disease should 
be relieved by the use of the stomach tube. 

In the management of these cases the first point is to restrict the 
use of fluids, reduce the size of the meals, and regulate the diet in 
accordance with the general plan outlined in the chapter on Chronic 
Indigestion. If the dilatation is marked, the stomach should be washed 
once a day. The general condition of the patient usually requires tonics. 
Rickets, if present, should receive its appropriate constitutional treat- 
ment. 

ULCER OF THE STOMACH. 

Ulceration of the stomach may be found in connection with several 
pathological processes which are quite distinct from one another: 

1. Ulcers in the Newly Bom. — These have already been referred to in 
the chapter on Haemorrhages of the Newly Born. The only character- 
istic symptom is haemorrhage. 



TUMOURS OF THE STOMACH. 337 

2. Ulcers Resulting from Acute Gastritis. — These also are not fre- 
quent. As a rule they give no symptoms except those of gastritis, 
although in several cases I have known severe haemorrhage to result 
from them. This symptom will be considered later. 

3. Tuberculous Ulcers. — These are quite rare. I met with gastric 
ulcers five times in one hundred and nineteen autopsies on tubercu- 
lous cases; however, the evidence was not conclusive in all of them 
that the ulcers were tuberculous; but in three the tubercle bacilli were 
found. Usually there were several small ulcers; in one case but two 
were present, the larger one being nearly three-fourths of an inch in 
diameter, and situated on the posterior wall near the middle of the 
greater curvature. All but one of these cases were in infants, one child 
being only ten months old. The ulcers gave no symptoms during life, 
and death took place from general tuberculosis. This is the history of 
nearly all the few cases on record. In one, however, reported by Casin, 
a tuberculous ulcer perforated the stomach and caused death from peri- 
tonitis. 

4. Simple Perforating Ulcers. — These are of great rarity and uncer- 
tain pathology. I have found but five recorded cases in young children 
in non-tuberculous patients, two of these being young infants. Botch's 
patient was but seven weeks old, and Cade's but two months. Two other 
cases were under four years old. 

The symptoms of ulcer before perforation are gastric pain and ten- 
derness, vomiting of blood, and often bloody stools. In most of these 
cases in children there were no symptoms until perforation, then fol- 
lowed collapse, sometimes high temperature, the rapid development of 
tympanites, and death from shock or from peritonitis. 

The prognosis is bad in all forms of ulcer of the stomach, except the 
small follicular variety. In this, however, the diagnosis can not posi- 
tively be made except by gastric haemorrhage, and it is only this which 
makes these cases serious. 

Treatment. — The treatment is absolute rest, ice by mouth, small 
doses of opium, and rectal feeding; later, bismuth, arsenic, or nitrate of 
silver. If symptoms of perforation occur the abdomen should be opened 
without delay, as offering the only chance of recovery. 

TUMOURS OF THE STOMACH. 

Although exceedingly rare, tumours of the stomach occur in child- 
hood, and are seen even in infancy. A case of sarcoma of the stomach in 
a child of three and a half years has been reported by Finlayson. It was 
apparently primary. The microscopical examination showed it to be of 
the spindle-celled variety. This writer could find no other recorded 
case under the age of fifteen. 
23 



338 DISEASES OF THE DIGESTIVE SYSTEM. 

Lijmphadcnoma of the stomach in a rachitic infant of eighteen 
months has been recorded by Eolleston and Lathan. There were mul- 
tiple tumours arising from the mucous membrane in the pyloric region. 
The case in many features resembled leukaemia. 

Six cases of cancer of the stomach in children under ten years are 
collected in an article by Osier and McCrae. Four of these were in 
young infants and probably congenital. One case, in a child of eight, 
presented the usual symptoms and lesions of the adult disease. 

HAEMORRHAGE FROM THE STOMACH (Hcematemesis). 

The most frequent variety of haemorrhage from the stomach, that 
is seen in the newly born, has already been considered. 

I have met with three fatal cases in young infants, the eldest being 
fifteen months old. In the first case there were symptoms of ordinary 
gastro-enteritis. On the seventh day the vomiting of blood began, and 
was repeated about ten or twelve times during the next twenty-four 
hours, when death took place. The blood was quite abundant, as much 
as a drachm of red blood being discharged at once. At autopsy there 
were found in the stomach about two ounces of dark-brown fluid, but no 
gross lesion was discovered, and no explanation of the bleeding. This 
haemorrhage was apparently capillary. In the second case there were 
symptoms of acute gastro-enteritis of thirty-six hours' duration. After 
this time there was marked abdominal distention with symptoms of col- 
lapse; then a profuse haemorrhage from the stomach, the child dying 
while vomiting blood. At least half a pint was discharged. The stom- 
ach contained at autopsy two ounces of dark fluid blood, and the mucous 
membrane was filled with minute ulcers extending quite through the 
mucosa. In the third case there was no vomiting of blood, but the 
patient died with symptoms of internal haemorrhage. There was blood 
in the upper part of the intestine, and the stomach was filled with blood ; 
it contained many small follicular ulcers resembling those found in the 
previous case. 

Haemorrhage from the stomach may occur in purpura, haemophilia, 
scurvy, and rarely in malaria. In young girls about puberty it may be a 
form of vicarious menstruation. Occasionally blood may be vomited in 
cases of haemorrhagic measles. Two cases are reported in which fatal 
haemorrhage followed the swallowing of a foreign body. In both, vomit- 
ing of blood occurred long after the original accident. In one case two 
and a half years had elapsed. The autopsy in this case showed impac- 
tion of the foreign body and ulceration into the arch of the aorta. Spu- 
rious haemorrhages may occur where blood has been swallowed and then 
vomited. The source of this is most frequently the nose or pharynx. 
It may happen in infants at the breast, where the blood is drawn from 



THE SWALLOWING OF FOREIGN BODIES. 339 

a fissure or ulcer in the nipple. The amount of blood vomited under 
these circumstances may be large enough to be quite alarming. It may 
be recognised by the child's general condition being normal, and by the 
presence of fissures or ulcers upon the nipple. It may sometimes be 
noticed that the vomiting of blood follows nursing from one breast and 
not from the other. 

Symptoms. — There may be no symptoms except those of internal 
haemorrhage, but this is rare. Usually there is vomiting of blood, and 
blood appears in the stools. If the haemorrhage is rapid and vomiting 
speedily occurs, the blood may be of a bright-red colour. If it has been 
long in the stomach it is of a dark-brown or black colour resembling 
coffee-grounds. The stools containing blood from the stomach are 
black and tarry in appearance. The general symptoms will depend upon 
the amount of blood lost. 

In a case where blood is vomited, the first point is to distinguish spu- 
rious from true gastric haemorrhage. The nose and pharynx, especially 
its posterior wall, should be carefully examined. If the child is at the 
breast, the nipples should be examined. In older children it is important 
to distinguish vomiting of blood from haemoptysis. This distinction is 
to be made in accordance with the rules laid down in text-books on gen- 
eral medicine. The prognosis is bad if the haemorrhage is due to ulcer, 
if it is very profuse, or if it occurs in young infants. When it occurs in 
connection with constitutional diseases the prognosis depends upon the 
original disease. 

Treatment. — Altogether the most efficient remedy is the suprarenal 
extract. It may be given very freely, at least two grains every half hour 
to a child of one year. The patient should be kept quiet, preferably upon 
the back; if there are signs of collapse, stimulants may be given hypo- 
dermically or by the rectum. No food or water should be given by the 
stomach for at least twenty-four hours after the haemorrhage has ceased. 

THE SWALLOWING OF FOREIGN BODIES. 

Between the ages of one and four years the habit of swallowing for- 
eign substances is a very common one. The variety of objects swallowed 
includes all those articles which the young child can reach and put into 
his mouth. The most common are detached parts of toys, marbles, peb- 
bles, buttons, and coins. Not only are such smooth articles swallowed, 
but also with equal readiness, sharp ones, such as pins of every variety, 
bits of glass, fragments of bone, nails, and small toy knives and forks, 
etc. At the time of swallowing, choking attacks, severe pharyngeal pain, 
and sometimes slight haemorrhage may occur. Symptoms referable to 
the oesophagus are very few. Nor in the stomach are symptoms often 
excited. While passing through the intestine there may be colicky pains, 



340 DISEASES OF THE DIGESTIVE SYSTEM. 

but in the majority of instances there are no symptoms whatever even 
with sharp or angular bodies. Impaction and perforation, while pos- 
sible, are extremely rare. The usual time required for a foreign body to 
traverse the intestinal tract is from four to ten days, but it may be con- 
siderably longer. If the body swallowed is a smooth one, it passes the 
sphincter ani without difficulty. But with sharp bodies there may be 
severe pain and sometimes haemorrhage. 

The diagnosis is often a matter of much difficulty, and without an 
X-ray examination a positive diagnosis is impossible. Very often when 
the physician is called because this condition is suspected by parents the 
alarm turns out to be a false one. 

It is most surprising to see the size, variety, and dangerous character 
of the foreign bodies which pass through the intestinal tract without 
causing any symptoms whatever. The expectant treatment is therefore 
by all means to be recommended. ~No emetics or cathartics should be 
administered. The diet should be abundant and composed of articles of 
food which leave much residue, e. g., coarse cereals, bread, and vegetables. 
Most of all operation should not be performed or even considered unless 
there are definite local symptoms. 

Quite distinct from such accidental swallowing of foreign substances 
as has just been described, is the practice of pulling off and swallowing 
fur from rugs, wool from toys or blankets, shreds from clothing, and a 
great variety of other substances. This habit is usually seen in nervous 
children, and often in those where some gastric irritation seems to excite 
an abnormal craving. In infants the quantity of the substance is gen- 
erally small and usually it provokes vomiting or the material is speedily 
passed by the bowel. Very recently in the Babies' Hospital a coloured 
child of about eighteen months passed in one day a large mass of hair 
which she had pulled from her own head. Another child in the same ward 
pulled into shreds and swallowed a large portion of the foot of a cotton 
stocking, and passed the same by the bowel the following day. Such oc- 
currences are not very common. It occasionally happens that the sub- 
stance swallowed does not pass the bowel but forms an intestinal tumour 
which may give rise to obscure and sometimes to severe symptoms of 
long duration. But more often the tumour forms in the stomach. These 
gastric tumours are usually composed of hair from the patient's own head. 
They are more frequently seen in older children than in infants, and 
usually in girls on account of the long hair. Many of these patients are 
of the nervous type. The habit may continue until a tumour of consider- 
able size may form, sometimes attaining two or three pounds in weight. 

The symptoms are vague until the tumour is discovered. There are 
usually gastric disturbances of a rather indefinite character. Epigastric 
pain is common, but vomiting is not especially marked. The general 
health may suffer but little for a long time. The tumour mav be mis- 



MALFORMATIONS AND MALPOSITIONS OF INTESTINES. 341 

taken for cancer, a displaced spleen or kidney, faecal impaction, or a tu- 
mour of the omentum. A correct diagnosis is seldom made until opera- 
tion is done. In a few instances the tumour has disappeared after 
catharsis. If operation is done the outcome is almost always favourable. 



CHAPTEE VI. 



DISEASES OF THE INTESTINES. 



R 



MALFORMATIONS AND MALPOSITIONS. 

Malformations are not very frequent, but are of great variety. 
With the exception of those situated at the lower end of the intestine 
they are not of much practical importance, for the condition is such 
ordinarily as to be incompatible with life. Malformations may be met 
with at any point in the canal, but most frequently in the rectum and 
anus. Aside from these, malformations of the large intestine are much 
less common than those of the small intestine. . 

Malformations of the Rectum. — In Fig. 50 are shown the usual vari- 
eties of malformation of the rectum. The most frequent is atresia of 
the anus (1). In this the 
cutaneous septum has not 
been absorbed, but the intes- 
tine is normal to its lower 
extremity. This form is read- 
ily curable by a surgical op- 
eration. In the next variety 
(2) the cutaneous orifice and 
the lower part of the rectum 
are normal, but a membrane 
separates this portion from 
the upper part of the gut; this is usually situated within two or three 
inches of the anus. The bulging of the lower part of the distended in- 
testine can usually be felt b} r the finger in the rectum, and a simple 
division of the membrane by a guarded bistoury may relieve the condi- 
tion. The third form (3) is more serious. Here the rectum terminates 
in a blind pouch at a variable distance from the anus, and is represented 
below by an impervious fibrous cord. The diagnosis of this condition 
can not positively be made without opening the abdominal cavity. The 
bulging of the intestine appreciable by the finger in the rectum, is the 
only point which differentiates the preceding variety from this one. In- 
stead of atresia of the rectum there may be stenosis of varying degrees, 
which may give rise to the usual symptoms of stricture. This is often 
curable by dilatation. 




Fig. 50. — Malformations of the Rectum. 
A, anus; R, rectum. 



342 DISEASES OF THE DIGESTIVE SYSTEM. 

Malformations of the Small Intestine. — There may be stenosis or 
atresia at any point, often at many points. Obstruction is much more 
frequent in the upper than in the lower part of the small intestine, the 
most common seat being the duodenum. Atresia is more often seen than 
stenosis. There may be a single point of obstruction, or the lumen of 
the intestine may be obliterated for a considerable distance, the intestine 
being represented only by a fibrous cord which connects the two open por- 
tions, or there may be no connection between them. In all cases the in- 
testine above is found very greatly distended, while that below is empty 
and usually atrophied. The causes of these multiple deformities are 
mainly two — foetal peritonitis and volvulus. In foetal peritonitis there 
are usually found bands of adhesions between the intestinal coils, and be- 
tween the intestine and the solid viscera. Syphilis has been assigned as 
a cause in many cases. Volvulus, or a twisting of the intestine during 
its development, is a more satisfactory explanation for the majority of 
the cases, especially where there are multiple points of atresia. All 
these conditions are beyond the reach of surgical treatment. The symp- 
toms appear soon after birth and are those of intestinal obstruction. 
The higher the point of obstruction the shorter the duration of life; it 
is rarely more than a week in any case of atresia; in stenosis it may 
be two or three months. 

Meckel's Diverticulum. — This is the remains of the omphalo-mesen- 
teric duct, which in foetal life forms a communication between the intes- 
tine and the umbilical vesicle. It is given off from the ileum, usually 
about a foot above the ileo-caecal valve. Most frequently it exists as a 
blind pouch from one-half to two or three inches long, communicating 
with the intestine. At the extremity of this there may be a fibrous cord, 
which is free in the abdominal cavity or attached to the umbilicus. In 
other cases the duct may remain pervious quite to the umbilicus, so that 
there is a faecal fistula. Prolapse of the mucous membrane of the duct 
may lead to an umbilical tumour, described elsewhere. Meckel's diver- 
ticulum, especially when present as a cord connecting the ileum with the 
umbilicus, may compress a coil of intestine, leading to obstruction or even 
strangulation. This may occur in infancy or later in life. 

Malpositions. — The ascending colon may be found upon the left side. 
There may be a complete transposition of the abdominal viscera. In 
cases of congenital umbilical hernia a large part of the intestines may be 
found in the tumour, and in diaphragmatic hernia they may be in the 
thoracic cavity. 

DIARRHOEA. 

The term diarrhcea is used to include all conditions attended by fre- 
quent loose evacuations of the bowels. These depend upon an increase 
in peristalsis and in the intestinal secretions. 



DIARRHCEA. 343 

The importance of diarrhceal diseases in children can best be appre- 
ciated by reference to the following table, showing the mortality of diar- 
rhceal disease in children under two years, as compared with that from 
certain infectious diseases for all ages. 

Deaths in New York City for Five Years. 



Measles, all ages 

Scarlet fever, all ages 

Pertussis, " " 

Typhoid, " " 

Diphtheria, " " 

Total deaths from five diseases 

Diarrhceal disease under two years . . 



3,378 
4,152 
2,000 
3,523 
10,277 

23,330 

26,563 



There are several important underlying factors upon which diarrhceal 
diseases depend. Their greatest frequency belongs to the first year of 
life; and after the second year a notable diminution both in frequency 
and severity is seen, and a fatal outcome is relatively rare. The extreme 
susceptibility in infancy is due to several causes. The digestive organs 
are severely taxed to provide for the needs of the growing body. The 
mucous membrane of the gastro-enteric tract of all infants is very deli- 
cate in structure, and even in those with good health is exceedingly 
vulnerable. This vulnerability is enormously increased in the very 
young, and in those who are feeble, delicate, or suffering from any form 
of digestive disorder. The mucous membrane of the digestive tract is 
furthermore constantly exposed to injury, either mechanical or chemical, 
and to infection. 

The next most striking fact about diarrhceal diseases is their preva- 
lence during the summer season. This is graphically shown in Fig. 51, 
where are given by months the mortality records for New York City 
for ten years. 

Diarrhceal diseases are especially frequent in cities and among the 
poor, for here are found united the three great causes — unfavourable 
hygienic surroundings, want of proper care, and improper food and feed- 
ing. Severe and even fatal cases are, however, met with among all 
classes and in all places. Their frequency and severity are both increased 
by want of cleanliness and bad hygiene. 

But intelligent care with proper feeding, even in very poor surround- 
ings, may enable children to escape serious diarrhoea in summer. 

Everything which lowers the general vitality increases the liability to 
diarrhceal diseases. Chronic disorders of digestion, marasmus, malnutri- 
tion, and rickets are especially important factors. 

Occasionally diarrhoea and dentition are closely associated, the bowels 



344 



DISEASES OF THE DIGESTIVE SYSTEM. 



quickly becoming normal when the teeth have pierced the gum. These 
cases, although rare, do occasionally occur. 

The form o( feeding is an etiological factor of the first importance. 
Of 1,943 fatal eases which I have collected, only three per cent had the 
brea^l exclusively. Fatal cases of diarrhceal disease in nursing infants 
are rare. It is not, however, artificial feeding per se that is to be blamed, 
but ignorant feeding and improper food. This is shown by the. relatively 
small number of deaths from diarrhceal diseases seen among the intel- 
ligent well-to-do. Breast-feeding requires but little experience, and may 
be very successfully done even by those with a very low grade of intel- 
ligence and among the poor; but artificial feeding is not successful 



F. 


c. 


Jan. 


Feb. 


Mar. 


Apr. 


May. 


June. 


July. 


Aug. 


Sept. 


Oct. 


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Dee. 


77° 


25° 
20° 
15° 
10° 

5° 

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403 660 4103 12,468 



1723 548 324 



Fig. 51. — Mortality from Diarrheal Diseases in New York for Ten Years in 
Children Under Five; Compared with the Mean Temperature for the Same 
Period. .mortality; , mean temperature. (Seibert.) 



unless carried on with much intelligence and experience, and at the same 
time with a certain amount of money to secure reliable materials, espe- 
cially pure milk. 

That impure milk can cause diarrhoea in infants is a fact that 
seems established beyond question. I have myself seen every one of 
twenty-three healthy children, all over two years old, occupying one 
dormitory cottage, attacked in a single day with diarrhoea, which was 
traced to this cause. The important question is whether impure milk, 
especially the bacterial contamination of milk, is the chief cause of the 
great increase of diarrhceal diseases in summer, or whether this is only 
one of the factors, others, especially atmospheric heat, being really more 
important. Since about the year 1890, when the enormous bacterial 
contamination of milk began to be appreciated, the opinion has pre- 
vailed that in this was to be found the real cause of the prevalence and 
fatality of diarrhceal diseases in summer. This belief carried with it 
the expectation that by furnishing to every artificially fed infant a clean, 
fresh milk, or milk which had been pasteurised or sterilised, this great 
cause of infant mortality could largely be removed. It is true that a 



DIARRHCEA. 



345 



great reduction in infant mortality from summer diarrhceal diseases has 
been effected during the last two decades; but it is also true that there 
has been quite as great a reduction in infant mortality in other seasons, 
and, in summer, from other causes than diarrhceal diseases. (See Fig. 
52.) This leads us to raise the question, whether the assumption that 



189 


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100 



Fig. 52. — Deaths Under One Year per 1,000 of Population Under One Year, 
New York City. A comparison of summer deaths from all causes with summer 
deaths from diarrhceal diseases for a period of twenty years. 

the bacterial contamination of milk is the great cause is correct, and also 
whether the lowered mortality in summer has not been brought about 
quite as much by other conditions, such as better hygiene and care and 
a better understanding of infant-feeding, as by the exclusion of germs 
from milk or their destruction by heat. 

In the years 1901 to 1903 an investigation 1 was undertaken by The 
Rockefeller Institute in co-operation with the Health Department of 
New York to secure data regarding the following points: (1) The re- 
sults in infant-feeding obtained with milk of different degrees of purity 
both in winter and in summer, as shown by the gain or loss in weight, 
the amount of gastro-intestinal disturbance, and the death rate; (2) 
the relation, if any, existing between the number of bacteria present in 
the milk and the frequency of diarrhceal disease; (3) whether any 
organisms with pathogenic properties could be found in milk to which 
diarrhceal disease could be ascribed as a cause; (4) whether the practice 
of heating milk — pasteurisation or sterilisation — affected the results ob- 

1 The full report of this investigation was published by Prof. William H. Park and 
the author in the Medical News, December 5, 1903, 



346 DISEASES OF THE DIGESTIVE SYSTEM. 

tained with any given milk; (5) to what degree older children as well 
as infants were affected by bacterial contamination of milk. 

Observations were made upon 592 bottle-fed infants living in tene- 
ments of New York; 202 were observed in winter and 390 in summer. 
The infants were well when the observations were begun, and were 
watched for a period of about three months, being visited regularly by 
physicians, who gave advice when needed. For some of the children 
no change was made in the milk which they were already taking; for 
others special milk was provided. Samples of milk as fed to the chil- 
dren were frequently examined as to the number and character of the 
bacteria present. Observations were possible upon infants taking (1) 
condensed milk, (2) the cheapest grade of store milk, such as is usually 
purchased by the poor, (3) a better grade of milk delivered in bottles, 
(4) the best bottled milk sold in the city, all of the above being pre- 
pared at home, (5) milk modified at milk depots and furnished to pa- 
tients in separate feeding-bottles. 

During the winter period of observation, the mortality was but 2.5 
per cent, and in but one instance was death due to disease of the digestive 
tract. The health of the infants observed was not appreciably affected 
by the kind of milk nor by the number of bacteria which it contained. 
The different grades of milk varied much less in the amount of bacterial 
contamination in winter than in summer, the cheap store milk averaging 
only about 750,000 per c.c. 

During the summer period, the mortality was 10.5 per cent, four- 
fifths of the deaths being due to diarrhoeal disease. The worst results 
were seen in those whose food was either the cheap grade of store milk 
or condensed milk, and in those who received the poorest care. The best 
results were seen in those whose food was the best grade of bottled milk, 
or modified milk furnished from milk depots, and in those who received 
the best care. 

The number of bacteria which milk may contain before it becomes 
noticeably harmful to the average infant in summer is not at all uniform. 
Of the usual varieties present, no strikingly deleterious results were seen 
until the number approached the one million mark. But much above 
this point injurious effects were usually manifest. Below it other factors 
rather than the number of bacteria seemed of greater importance in 
producing diarrhoea. Thus in condensed milk, prepared as it usu- 
ally was with hot water, the bacterial contamination was relatively small, 
yet the results were almost as bad as with the most highly contaminated 
milk. 

No relationship could be discovered between any special forms of 
bacteria present in the milk and the health of children. The pathogenic 
properties of 139 varieties of bacteria isolated from milk were tested 
upon animals in various ways, chiefly by feeding pure cultures to young 



DIARRHOEA. 



347 



kittens. The results were negative. Nor could a relationship be estab- 
lished in any other way between any special form of bacteria in milk 
and the summer diarrhoeas of infancy. 

To test the effect of heating milk, observations were made during 
two summers upon 92 infants who were taking the modified milk pre- 
pared at a milk depot. The milk used was from a good farm, and had 
been kept properly cooled. The infants were divided into two groups as 
nearly alike as possible. To one group the milk was given pasteurised 
(165° F. for thirty minutes), to the other group the same kind of milk- 
was given raw. All the infants were well at the beginning of the period 
of observation. The results are shown in the following table : 



Food. 


Total 

number of 

infants. 


Remained 
well entire 
summer. 


Had 

severe 
diarrhoea. 


Average 

days 
diarrhoea. 


Deaths. 


Pasteurised milk containing 1,000 
to 50,000 bacteria per c.c. at the 
time of use 

Raw milk containing 1,200,000 to 

20,000,000 bacteria per c.c. at 

the time of use 


41 
51 


31 
17 


10 
34 


4 
11| 


1 

2 



Thirteen of the fifty-one infants on raw milk were changed before 
the end of the season to pasteurised milk because of serious diarrhoea; 
but for this the results with raw milk would have been even more un- 
favourable. A similar experiment was made a third season with almost 
identical results. Although the number of cases is not large, the results, 
which were practically uniform for three successive seasons, show un- 
mistakably that in hot weather raw milk, although from a good source, 
but at the time of feeding highly contaminated with bacteria, causes ill- 
ness in a much larger number of cases than when it has been previously 
heated. 

After the first two years, children are much less affected by bacteria 
in milk. The observations seemed to show that milk from healthy cows, 
produced under cleanly conditions and kept at a temperature below 
60° F., although containing large numbers of bacteria, sometimes 
amounting to many millions per c.c, might be taken in considerable 
quantities and for long periods by children over three years old, without 
any appreciably harmful effects resulting either from the living bacteria 
or their toxins. A single example is typical of a number of observations 
made. An orphan asylum, containing 650 children from three to four- 
teen years old, used during an entire summer milk in which the bacteria 
ranged from 2,000,000 to 20,000,000 per c.c. ; yet during this period there 
occurred no case of 4 diarrhoea of sufficient severity to call a physician. 
The milk was kept cold (below 60° F.) until used; but was given with- 
out sterilisation. 



348 DISEASES OF THE DIGESTIVE SYSTEM. 

Mere numbers of bacteria certainly appear to count for much less 
than was once supposed. But the fact should not be overlooked that 
milk abounding in bacteria because of careless handling is also always 
liable to contain pathogenic organisms derived from human or animal 
sources. These observations, continued for three seasons and giving 
each summer nearly identical results, indicate that we are to seek else- 
where than in a moderate bacterial contamination of milk the great 
cause of summer diarrhoeas. Though it is clear that excessive contam- 
ination is highly detrimental to infants, we must certainly look to the 
other factors for the explanation of a very large, possibly the largest, 
proportion of the cases. Of the other factors, atmospheric heat is clearly 
first in importance. This may act by so interfering with normal diges- 
tion and metabolism as to lead to the formation within the body of in- 
jurious substances which excite diarrhoea ; or it may favour the excessive 
growth of bacteria ordinarily present in the digestive tract. In this 
group of cases the role of the bacteria seems to be secondary, though 
perhaps a very important one. According to this hypothesis, the cause 
of the diarrhoeas under consideration is not something introduced from 
without, but something produced within the body itself. 

Another group of diarrhceal diseases exists which may be due to in- 
fection introduced from without, through water, milk, or other food; 
to these the term dysentery is more often applied. These cases have 
been found to be associated with definite bacteria or amoebae. It is likely 
that intestinal disease of this type may supervene upon the preceding one. 

ACUTE INTESTINAL INDIGESTION AND INTOXICATION. 

The cases included in this chapter comprise many types which, how- 
ever, are closely allied and shade into one another. Though the extremes 
of the series differ as widely as possible, yet intermediate types of almost 
every grade are met with. They are discussed under a single heading, 
since they have no essential anatomical differences, nor, so far as yet 
determined, do they differ etiologically. Some of the attacks are so 
mild in character that in children with normal resistance, and receiving 
prompt treatment, they may last but a few hours. On the other hand, 
they may be so rapid in development and so severe as to result in death 
in a few hours ; or, beginning with less intensity, they may be the start- 
ing point of prolonged functional disorders or may prepare the way for 
the development of infectious processes. 

Etiology. — The most important causes have been mentioned in the 
foregoing discussion on the General Etiology of Diarrhceal Diseases. A 
predisposition to attacks is furnished by summer weather, a delicate con- 
stitution, and any previous derangement of digestion. The exciting cause 
of an attack may be the use of improper food, overfeeding or some sudden 



ACUTE INTESTINAL INDIGESTION AND INTOXICATION. 349 

change in food as in weaning; but, the food remaining unchanged, 
it is often other influences affecting the child, such as summer heat. 
The most striking thing about these cases is their prevalence during 
hot weather. Year after year are repeated in New York the conditions 
which are graphically represented in Fig. 51, viz., an epidemic which, 
beginning in June, rapidly increases in severit}', reaching its height usu- 
ally in Juty, from which time it diminishes steadily, regularly coining 
to an end in September. "What is true of Xew York is true also of Phil- 
adelphia, Chicago, and other large cities of the temperate zone. The 
severity of the epidemic bears a fairly close relation to the height of the 
summer temperature. Thus in Chicago and Philadelphia, of the deaths 
under one year, 32 per cent are due to acute gastro-intestinal diseases; 
in N"ew York, 27 per cent; in Boston, 19 per cent; in London, only 13 
per cent. A comparison of the mortality and temperature curves shows 
that while the mean temperature rises gradually during April and May, 
it is not until a certain temperature is reached, that any notable increase 
in diarrhceal diseases begins. 

Despite the fact that since 1886 many series of bacteriological studies 
of the intestinal discharges have been made by Booker and Park in 
this country, by Baginsky, Escherich, and others in Germany, our knowl- 
edge of this subject is still very incomplete. The conditions are exceed- 
ingly complicated, and the problem is a very difficult one. So far as is 
now known, no one form of bacteria can be assigned as the cause of this 
group of diarrhoeas. There seems to be evidence that the Shiga bacillus 
may produce diarrhceal disease which clinically does not differ from this 
type. But it is wanting in so large a proportion of cases, that it can 
not be regarded as a specific cause. With existing knowledge it seems 
probable that there are a number of organisms present in the intestine 
in disorders of digestion, which, under favourable conditions, may 
multiply to such a degree as to produce serious disturbances. But the 
role of the micro-organisms may be regarded as a secondary one. 

There are certain cases in which toxic symptoms of a severe type 
develop abruptly in children previously quite well. These only are to 
be regarded as examples of acute milk poisoning. Although the bacteria 
in the milk may have been previously destroyed by sterilisation, the 
toxins produced by them may still be present. This is doubtless the 
explanation of the simultaneous development of several cases in families 
or institutions. 

We can not believe that direct contagion is the usual way in which 
this disease is spread. When occurring in institutions or in families, 
it usually happens that a number of children are attacked simulta- 
neously rather than successively, this indicating a common cause, usu- 
ally to be found in the food, the surroundings, or the atmospheric con- 
ditions. 



350 DISEASES OF THE DIGESTIVE SYSTEM. 

Lesions. — In the milder cases which end in recovery, the anatomical 
changes are negligible. In those which prove fatal from the disease 
itself, or from some associated condition, the lesions are, in brief, a 
superficial catarrhal inflammation affecting the entire gastro-enteric 
tract, hut varying much in severity in the different regions and in the 
different rases. The colon, the lower ileum, and the stomach are apt to 
suffer most, the duodenum and the jejunum least. 

Th> G m Appearances. — These may show but little that is abnormal. 
The walls of the stomach may be coated with mucus, and the mucous 
membrane may show intense congestion, generally in patches, or it may 
he pale The mucous membrane of the small intestine may be pale 
throughout ; there are often irregular areas of congestion, or a very 
intense congestion of a large part of its surface, particularly in the 
ileum. With this there may be redness and swelling of Peyer's patches 
ami the solitary follicles. In the colon the mucous membrane is con- 
:. ('specially upon the ruga?. The solitary follicles are usually 
swollen. The changes described are not at all uniform, and do not differ 
very greatly from the appearances often seen in the intestines when 
patients have died of other diseases. 

In the cases classed clinically as cholera infantum, the pathological 
changes are more characteristic. The greater part of the small intes- 
tine, and sometimes the entire colon, are distended with gas, and contain 
material of a grayish-white colour about the consistency of a thin gruel. 
It has a mawkish odour, but usually not a very offensive one. The 
mucous membrane of the entire intestinal tract has in most cases a pale, 
M washed-out " appearance. Sometimes this is seen only in the small 
intestine, while there are areas of congestion in the colon. If cholera in- 
fantum has been engrafted upon some other pathological process in the 
intestines, as is not infrequent, there is found post-mortem evidence of 
this in the form of severe catarrhal inflammation, sometimes old ulcera- 
tions. 

The Microscopical Appearances. — Unless autopsies are made very 
soon after death — at most within four hours — it is not safe to draw 
conclusions from the conditions found, as post-mortem changes take place 
readily, and resemble those of the disease under consideration. This 
applies particularly to the condition of the epithelium. 

The essential lesion consists in degenerative changes in the epithe- 
lium of the stomach and intestines. The cells may still be present, but 
with the cell protoplasm and nuclei so changed that they do not stain 
normally. In more <(>xvv<' and prolonged cases the superficial epithelium 
in pis niirelv destroyed; these changes mark the beginning of 

ileo-colitis. 

The change.- in and ahout the blood-vessels are variable. The small 
- may he distended, and there may be haemorrhages or an exuda- 



ACUTE INTESTINAL INDIGESTION AND INTOXICATION. 351 

tion of leucocytes in their neighbourhood. These appearances arc Been 
either in the mucous or submucous layer. Peyer's patches and the lymph 
nodules may be enlarged from cell-proliferation. Pathologically no sharp 
line can be drawn between these lesions and those of the early stage of 
ileo-colitis ; the latter affect the lower ileum and colon chiefly, often ex- 
clusively, are more advanced, and involve the deeper parts of the intes- 
tinal wall. 

Lesions in Other Organs. — These are much less frequent and less 
severe than in the more protracted cases of ileo-colitis. Acute bronchitis 
and broncho-pneumonia are frequent. Acute degeneration of the kidney 
is found to some degree in every case which is severe enough to cause 
death, and in a few there is acute nephritis. In rare cases a general 
septicaemia, due most frequently to the streptococcus, is present. Degen- 
erative changes are sometimes found in the liver cells, and even in the 
nervous centres. 

Symptoms. — Clinically, these cases may be divided into three groups : 
(1) The mild form, with definite local symptoms, but few general ones; 
they may be of short duration or protracted; (2) the severe form in 
which there are not only local but marked constitutional symptoms, 
fever, etc.; (3) cholera infantum, the more severe and fatal type met 
with. 

The Mild Form. — In infants, acute indigestion is seldom limited 
either to the stomach or to the intestine, although in one case the dis- 
turbance of the stomach is slight and that of the intestine serious, and 
in another the reverse may be observed. In these little patients the 
intestinal symptoms are more frequent, and, as a rule, more severe than 
those referable to the stomach. In older children it is not uncommon 
to see the intestinal symptoms alone. In infants, if the attack develops 
suddenly, gastric symptoms are usually present; if more gradually, they 
are usually absent. The local symptoms are colicky pain, tympanites, 
and later diarrhoea. The constitutional symptoms, prostration and 
nervous disturbances, are slight or absent. Pain is indicated by the 
sharp, piercing cry, great restlessness, and drawing up of the legs. Tym- 
panites is rarely very marked. The stools are always increased in number 
and are from four to twelve a day. If more frequent they are very 
small. The first stools are more or less faecal, but this character is soon 
lost. The colour is at first yellow, then yellowish-green, and finally often 
grass-green. This colour is due to biliverdin. If the child has been 
taking milk, masses of undigested milk, chiefly fat, are present. The 
reaction of the stools is almost invariably acid. The odour may be sour, 
or it may be foul. The stools are much thinner than normal, and often 
frothy from the presence of gases. Blood is not present, nor is much 
mucus seen, unless the symptoms have lasted several days. The micro- 
scope shows, in addition to food-remains, epithelial cells, usually of the 



DISEASES OF THE DIGESTIVE SYSTEM. 

cylindrical variety, which are numerous in proportion to the severity and 
duration of the attack. The bacteria are the ordinary forms found in 

the faves. 

The course and termination of the disease depend upon the previous 

condition o( the patient, the nature of the exciting cause, and the treat- 
ment employed. In a previously healthy child, if the cause is at once 
removed and proper treatment instituted, the severe symptoms rarely 
last more than a day or two, and in four or five days the patient may be 
quite well. In delicate infants, a severe attack of acute intestinal in- 
digestion in the hot season is likely to prove the first stage of a patholog- 
ical process which may continue until serious organic changes in the 
intestine have taken place. This result may not follow the first attack, 
l)ii t one is often succeeded by others until it occurs. If circumstances 
are such that proper dietetic treatment and general hygienic measures 
can not be carried out, this termination is very common. 

In older children most of the cases seen are of the milder type. The 
onset is often with vomiting; pain is generally mild and precedes diar- 
rhoea by several hours. It is seldom localised but is more often re- 
ferred to the navel. The stools are loose, frequent, and contain un- 
digested food, and are of almost every conceivable colour and variety. 
The temperature, if elevated at all, is so only for a short time. 
There is general anorexia and a coated tongue. With proper treatment 
the attack is usually over in a few days, being very seldom fol- 
lowed by the severer types of diarrhoea, as is so commonly the case with 
infants. 

The Severe Form. — This may follow after several days of an ap- 
parently mild attack, especially during hot weather or if improperly 
treated. In the cases developing suddenly, the clinical picture is quite a 
definite one. 

An infant is restless, cries much, sleeps but a few minutes at a time, 
and seems in distress. The skin is hot and dry, the temperature rises 
rapidly to 102° or 103° F., sometimes to 106° F., and all the symptoms 
indicate the onset of some serious illness. He may lie in a dull stupor, 
with eyes sunken, weak pulse, and general relaxation, or there may be 
restlessness, excitement, and even convulsions. There may be great 
thirst, so that everything offered is eagerly taken, or everything may be 
refused. Vomiting may be an early and important symptom. It is first 
of food, often that which was taken many hours before; retching con- 
tinues even after the stomach has been emptied, so that mucus, serum, 
and sometimes bile may be ejected. Vomiting does not usually persist 
throughout the attack, and in many cases it is absent altogether. Diar- 
rhoea is sometimes delayed for twenty-four hours or even longer after 
the beginning of the grave constitutional symptoms. At first there are 
faecal stools, then great bursts of flatus, with the expulsion of a thin 



ACUTE INTESTINAL INDIGESTION AND INTOXICATION. 353 

yellow material with an offensive odour. Four or five such discharges 
may occur in as many hours. At other times the stools are gray, green, 
or greenish-yellow, and sometimes brown. The characteristic features 
are the amount of gas expelled, the colicky pains preceding the dis- 
charges, and the foul odour. After the first day the stools may be almost 
entirely fluid, varying in number from six to twenty a day, and often 
large even then. Their offensive character usually continues. After 
two or three days mucus appears. The microscopical examination of the 
stools shows great numbers of separate epithelial cells, and sometimes 
groups of cells attached to a basement membrane. In addition there 
may be leucocytes and some red blood-corpuscles. 

In many cases the free evacuation of the bowels is followed by a drop 
in the temperature and subsidence of the nervous symptoms, and the 
child may fall asleep. The prostration, though often great in the be- 
ginning, may not be of long duration. Under the most favourable cir- 
cumstances, after one or two days of severe symptoms, convalescence may 
take place. The stools continue frequent for five or six days, but grad- 
ually assume their normal character, and recovery follows. The chief 
factors contributing to such favourable results are a good constitution 
on the part of the child, prompt and intelligent treatment at the outset, 
and proper feeding afterward. 

If the circumstances are not so favourable, if the patient is a very 
young or delicate infant, there may be no reaction from the first severe 
symptoms, and the attack may terminate fatally in from one to three 
days. In such cases the temperature remains high ; the stomach may 
or may not be disturbed; but the diarrhoea, prostration, and nervous 
symptoms continue, and death occurs from exhaustion, in coma or con- 
vulsions. Instead of a rapidly fatal termination, the severity of the 
early acute symptoms may abate somewhat, and the attack assume the 
character of ileo-colitis, with a lower but continuous temperature of 
100° to 102° F., frequent mucous stools, wasting, etc. The urine is 
scanty and concentrated, and in most of the severe cases with very high 
temperature contains a small amount of albumin, and occasionally a 
few hy aline and granular casts. These are the result of degenerative 
changes in the renal epithelium. In rare cases there are evidences of 
acute nephritis. Broncho-pneumonia is sometimes seen. 

It not infrequently happens, after the storm of the acute attack with 
its high temperature, intense prostration, and grave nervous symptoms 
is passed, and the stools are so much improved that the patient is re- 
garded as out of danger, that all the former symptoms may develop with 
such rapidity and severity as sometimes to carry off the patient in from 
twelve to twenty-four hours. Such relapses are generally excited by 
some mistake in the diet, usually that of allowing milk too soon. The 

amount of milk given may be small, and yet the symptoms follow its 
24 






DISEASES OF THE DIGESTIVE SYSTEM. 



OCT 14 

3 



A 



V 



I 



li 



?s5i 



\i* 



1 



administration s<^ soon thai there can be little doubl regarding tlie con- 
Dection between them (Fig. '><*>). Besides such severe cases, many- 
milder relapses are 
seen ; the cause is usu- 
ally some error in 
diet. 

Cases without Di- 
arrhoea. — Attacks of 
acute intestinal indi- 
gestion with severe 
intoxication in which 
there is no diarrhoea, 
but constipation in- 
stead, are most puz- 
zling and frequently 
most serious. Fortu- 
nately, they are not of 
common occurrence. I 
have, however, seen 
several striking exam- 
ples with very high 
temperature, grave 
nervous symptoms, 
and sometimes marked 
abdominal distention in which it seemed almost impossible to move the 
bowels by drugs. Castor oil, calomel, and salines have in some cases 
been tried in succession in four or five times the ordinary doses with- 
out the slightest effect, even when supplemented by frequent intestinal 
irrigation. It has sometimes been nearly two days before free move- 
ments were finally produced. These are often exceedingly foul. It is 
somewhat difficult to explain such cases. There seems to exist for the 
time almost complete intestinal paralysis. The toxic materials are locked 
up in the small intestine, for the colon is frequently quite empty. When 
one meets such a case he can appreciate the fact that diarrhoea is a con- 
ative process of the greatest possible value. 

In children over two years old there are seen some features which 
differ from those of the cases above described as occurring in infants. 
The attacks are more often due to other causes than to milk. Vomiting 
docs not occur so readily as in infants, pain is a more prominent symp- 
tom, and the temperature, as a rule, is lower. The nervous symptoms are 
much less prominent. Skin eruptions, however, are more frequently 
seen, particularly urticaria, which is a feature of most severe attacks, 
and in obscure cases has some diagnostic value. Although often begin- 
ning with severe symptoms, these cases usually make good recoveries; 



Fig. 53. — Acute Intestinal Intoxication with Fatal 
Relapse. Infant five months old; early symptoms, 
both intestinal and nervous, severe; rapid improvement 
followed stopping milk, free catharsis and irrigation. 
After stools had been nearly normal for three days re- 
lapse occurred, apparently from adding milk to the diet, 
although less than two ounces a day were given. Au- 
topsy: Only mild intestinal lesions were present; other 
organs essentially normal. 



ACUTE INTESTINAL INDIGESTION AND INTOXICATION. 355 

there is much less danger of their going on to the development of ileo- 
colitis than in the case of infants. 

Diagnosis. — The acute indigestion manifested by vomiting and diar- 
rhceal stools which marks the beginning of so many febrile diseases in 
infancy, particularly scarlet fever, pneumonia, malaria, and influenza, 
is often difficult to distinguish from more severe attacks with intestinal 
intoxication. The question to decide is whether the digestive symptoms 
are the cause or the result of the fever. It is sometimes not until the 
case has been watched for some time that one can be certain. Usually 
where digestive symptoms are secondary they diminish after the first day 
or two, although the severity of the general symptoms may steadily in- 
crease. Where the nervous symptoms are prominent at the outset, it 
is sometimes difficult to exclude meningitis. I have seen many cases 
where great doubt existed for several days. One should always hesitate 
to make a diagnosis of meningitis when marked diarrhoea is present. 

Prognosis. — Attacks of intestinal indigestion do not often prove 
fatal, except in young infants or those already suffering from malnutri- 
tion. In all cases the prognosis depends upon the previous health of the 
child, his surroundings, the season of the year, and whether or not the 
case receives prompt and proper treatment. A continuously high tem- 
perature and severe nervous symptoms are bad prognostic signs. The 
existence of rickets, pertussis, or any other disease, greatly increases the 
gravity of the attack. 

Prophylaxis. — A better understanding of the etiology brings with it 
great possibilities in the prevention of this disease. 

Prophylaxis must have regard, first, to the hygienic surroundings of 
children, and to all sanitary conditions of cities. City children should 
be sent to the country, whenever it is possible, for the months of July 
and August. Where a long stay is impossible, day excursions do much 
good. The fresh-air funds and seaside homes have done much in New 
York to diminish the mortality from diarrhceal diseases. 

The second part of prophylaxis relates to food and feeding. Mater- 
nal nursing should be encouraged by every possible means. Nothing is 
better established than the close relation existing between artificial feed- 
ing and diarrhceal diseases. Yet, as stated elsewhere, it is not artificial 
feeding per se, but ignorant and improper feeding. Among infants in 
private practice who are properly fed these attacks are not common. 

Overfeeding is particularly to be avoided during days of excessive 
heat. It is at such times an excellent rule with infants to diminish each 
feeding by at least one-half, making up the deficiency with water, and to 
give water very freely between the feedings. In summer all water given 
to infants or young children should be boiled. Children, like adults, 
require less food in very hot weather, but more water. Infants cry more 
from thirst and heat than from hunger, and even those at Hie breast are 



366 DISEASES OF THE DIGESTIVE SYSTEM. 

likely to be given too much food. Infants should inner be fed more fre- 
quently, but always less frequently, during hot weather. 

A very important work in practical philanthropy among the poor of 
our Large cities in summer is to provide means for supplying pure milk 
to infants. This has been done on a large scale in many American 
cities, and it is one of the important agencies that have affected a decided 
reduction in the death-rate from diarrhceal disease. It is not enough to 
furnish to the poor a pure, clean milk in bulk, or even in sealed quart 
bottles. The advantages of such milk may be entirely lost by the way 
in which it is eared for in the home or the way in which it is fed to 
infants. Since the milk must usually be kept at home without ice, steril- 
isation at 212° F. is advisable. When milk is distributed from milk 
depots, a physician should be in charge who can keep a general super- 
vision over the children, and advise as to the quantity of food, number 
of feedings, and the formula to be used. His work should be supple- 
mented by visits of nurses to the homes of patients. An essential feature 
is to keep such close supervision over the infants as to recognise at once 
and promptly treat slight disturbances of digestion. 

But even more important than pure milk is the education of the 
poor in all matters relating to infant feeding and hygiene. In no way 
can this educational work better be done than in connection with milk 
distribution. 

Hygienic Treatment. — If the attack is a severe one and occurs in the 
excessive heat of midsummer, and does not readily yield to treatment, 
the child should, if possible, be sent to a cooler place. Convalescent cases 
should also be sent away on account of the dangers of relapse. Usually 
the seashore is to be preferred to the mountains, but this is not so impor- 
tant as that the child shall go where it can be taken most quickly and 
can secure the best food and the best surroundings. Children must not 
only be sent away; they must be kept away until quite recovered. In 
cases which have become somewhat chronic, more can sometimes be 
accomplished by a change of air than by all other means. 

Fresh air is of the utmost importance for all diarrhoeal cases in sum- 
mer. No matter how much fever or prostration there may be, these 
children do better if kept out of doors the greater part of the day. 
Nothing is so depressing as close, stifling apartments. Children should 
be kept quiet, and especially should not be allowed to walk, even if they 
are old enough and strong enough to do so. They can be kept out in 
carriages in perambulators, or in hammocks. 

The clothing should be very light flannel; a single loose garment is 
preferable. Linen or cotton may be put next the skin if this is very 
sensitive and there is much perspiration. At the seashore and in the 
mountains, care should be taken that sufficient clothing at night is 
supplied. 



ACUTE INTESTINAL INDIGESTION AND INTOXICATION. 357 

Bathing is useful to allay restlessness, as well as for the reduction of 
temperature. For the latter, only the tub bath can be relied on. The 
temperature of the bath should be about 100° F. when the child is put 
into it, and should then be gradually reduced to 80° or 85° F. by adding 
ice. The bath should be continued, with gentle friction of the body, for 
from five to twenty minutes. 

Scrupulous cleanliness should be secured in the child's person and 
clothing. Napkins, as soon as soiled, should be removed from the child 
and from the room and placed in a disinfectant solution. Excoriations 
of the buttocks and genitals are to be prevented by absolute cleanliness 
and the free use of some absorbent powder, such as starch and boric acid. 

Dietetic Treatment. — It is of the first importance to remember that 
during the early stage of the acute cases, digestion is practically arrested. 
To give food at this time, manifestly can do only harm. 

In nursing infants the severe forms of the disease are extremely 
rare ; but the breast should be withheld so long as a disposition to vomit 
continues, and no food whatever given for at least twenty-four hours. 
Thirst may be allayed by giving frequently, but in small quantities, 
boiled water or thin barley or rice water. If these are refused or vom- 
ited, absolute rest to the stomach will do more than anything else to 
hasten recovery. After the stomach has been allowed to rest for twenty- 
four hours, it is generally safe to permit a nursing child to take the 
breast tentatively. The intervals of nursing should not be shorter than 
four hours, and the amount allowed at one feeding should not be more 
than one-fourth the usual quantity. This may be regulated by allowing 
an infant to nurse at first only two or three minutes. Between the nurs- 
ings may be given boiled water or barley water. Nursing may be grad- 
ually increased, so that in three or four days the breast may be taken 
exclusively. If there is any reason to suspect the quality of the breast- 
milk, such as menstruation or pregnancy, it may be necessary to stop the 
nursing for a longer time. 

In infants under four months who are being artificially fed, all food, 
and especially milk, should be stopped at once. Milk should not only 
be withheld during the period of acute symptoms, but for several days 
thereafter. Besides the articles mentioned above as suitable for the 
period of most acute symptoms the following substitutes for milk will 
be found useful: rice or barley water or whey; the farinaceous foods, 
and broth or bouillon made of veal, chicken, mutton, or beef. ^Water 
may be allowed freely at all times unless there is much vomiting. 

When milk is begun it should be remembered that the fat is more 
likely to disturb digestion than any other element. For this reason 
skimmed milk, fat-free milk, buttermilk, or condensed milk, are use- 
ful. The first three mentioned should be sterilised. At first they 
should be well diluted and very gradually increased in strength. (For 



DISEASES OF THE DIGESTIVE SYSTEM. 

details, Bee article on Feeding.) Wet-nurses are nol to be employed 
daring the acute symptoms, bu1 during the period of prolonged malnu- 
trition which follows an acute attack they may be of the greatest service. 

The same genera] principles of feeding should be applied in older 
children. All food is to be withheld until the vomiting ceases, when 
broths and beef juice may be given; later, buttermilk or kumyss and 
sterilised skimmed milk, or thin gruels. Solid food should not be 
allowed for several days after the stools have become normal. 

Medicinal and Mechanical Treatment. — It must be borne in mind 
that we are not treating an inflammation of the stomach or intestines, 
although such may be the ultimate result of the process. The essential 
condition, it should be remembered, is one of indigestion and intoxica- 
tion arising from the intestinal contents — food-remains from arrested 
digestion, altered secretions, acids, irritating and toxic substances pro- 
duced by chemical and bacterial action — to which not only the constitu- 
tional but the local symptoms are chiefly due. We can hardly do better 
than to imitate and assist Nature in her treatment of this condition. 
Let us consider what this is. Lest too much food be swallowed, appetite 
is taken away; by vomiting, the stomach is emptied; to neutralise the 
acid poisons in the intestine, an alkaline serum is poured out from the 
intestinal walls; to remove irritant poisons, increased peristalsis is ex- 
cited. 

The first indication is, therefore, to evacuate the stomach and the 
entire intestinal tract at the earliest moment, and to do this as thor- 
oughly as possible. Under no circumstances should the treatment be 
begun with the use of measures to stop the discharges. To empty the 
stomach is not necessary in every case, since the initial vomiting may 
have done this effectively. Whenever vomiting persists one should im- 
mediately resort to stomach-washing. A single washing is generally suf- 
ficient, and if employed at the outset may do much to shorten the 
attack. With high fever and great thirst, it is often advisable to leave 
a few ounces of water in the stomach. If the vomited matters have 
been very sour, ten grains of bicarbonate of soda may be introduced with 
the portion which is to be left behind. As a substitute for stomach- 
washing in children over two years old, or where it can not be employed, 
copious draughts of boiled water may be given. This is taken readily, 
and as it is usually vomited almost at once it may cleanse the stomach 
thoroughly; but it is inferior to stomach-washing. 

To clear out the small intestine, only cathartics are available. For 
the colon, we may in addition employ irrigation. Calomel, castor oil, or 
the salines may be used as cathartics, and enough of any one of them 
must be given not simply to move the bowels, but to clear out the intes- 
tinal tract thoroughly. There is little danger from too free purgation 
at the outset. Calomel has the advantage of ease of administration: 



ACUTE [NTESTINAL ENDIGESTION AND [NTOXICATION. 359 

one-fourth of a grain should be given every fifteen or twenty minutes 
up to six or eight doses. When the stomach is not disturbed, I prefer 
castor oil in most cases, as it sweeps the whole canal, causes little grip- 
ing, is very certain, and its after-effects are soothing. Two drachms 
should be given to a child six months old, and half an ounce to one of 
four years. Of the salines, the best are the sulphate of soda and Rochelle 
salts; from one to three drachms may be given, well diluted, divided 
into four or five doses, at twenty-minute intervals. 

The occasional nse of cathartics is an important part of the later 
treatment. Whenever there are signs of an accumulation, or fresh symp- 
toms of intoxication develop, such as increase in temperature, nervous 
symptoms, etc., another thorough cleaning out of the intestinal tract is 
indicated. The accumulation may not be the result of food, but simply 
of intestinal secretions. So long as the processes of fermentation and 
decomposition continue active, the indications are to facilitate elimina- 
tion, not to check the discharges. 

Early irrigation of the colon is advisable in all cases, as it hastens the 
effect of the cathartic and removes at once much irritating and offensive 
material. It should be done two or three times the first day, but after- 
ward once daily is generally sufficient. A saline solution (one table- 
spoonful of salt to two quarts of water), at a temperature of about 
100° F., is to be preferred; and a rectal tube well inserted should always 
be used. Thorough initial evacuation, no food, but plenty of water for 
twenty-four hours, and careful feeding after that time, are all the treat- 
ment that is necessary in most cases. 

Other drugs are of secondary importance. Their value is certainly 
very much overestimated. It may be questioned whether as yet any 
proper antiseptic treatment of the gastro-enteric tract is possible. 

Of the drugs which are used to influence the intestinal process, 
bismuth is to be preferred. It has the advantage that it rarely causes 
vomiting, and that most of its preparations can be given in large doses. 
The subcarbonate is the safest. It may be given in doses of from five 
to fifteen grains every two hours, to a child of one year. Like the sub- 
nitrate it is insoluble and is best given suspended in mucilage. It 
usually blackens the stools. It may be kept up throughout the attack. 
The best results seen from acids are in the later stages and in the sub- 
acute cases ; of the dilute hydrochloric acid, from four to ten drops may 
be given, best alone, but well diluted. Alkalies are of value only in the 
acute stage, especially where there is acid fermentation in the stomach, 
with vomiting and eructations of gas. Lime-water, bicarbonate of soda, 
magnesia, or chalk-mixture may be employed. My own experience leads 
me to place little reliance upon astringents. They do little good, and 
often much harm. They are indicated only in the catarrhal diarrhoea 
which often follows the symptoms of acute intoxication, but may be 



300 nisi \si B OF nil DIGESTH 1 SYSTEM. 

- .1 in tli is condition in combination with opium. A 
stringent i> tannalbin, which may be given in two-grain doses 
. two hours to an infant of one year. 

While opium in some form is required in many cases, as often used 

it undoubtedly does great harm. The chief indications for opium are 

frequency of movements and severe pain. It is contraindicated 

until the intestinal tract has been thoroughly emptied by cathartics and 

• when the number of discharges is small, particularly if 

ire very offensive : it is especially to be avoided in the early stage 
of very acute cases, and never to be given when cerebral symptoms and 
high temperature coexist with scanty discharges. Opium is admissible 
in the early part of the disease after the tract has been thoroughly emp- 
tied. It is particularly indicated when there is a persistence of large, 
fluid movements attended by symptoms of collapse, and in all cases 
approaching the cholera-infantum type. In such circumstances mor- 
phine should be given hypodermic-ally, one-sixtieth of a grain to an 
infant of six months, to be repeated in two hours if no effect is seen. 
Opium is useful during convalescence, when the administration of food 
is immediately followed by a movement of the bowels; and when with- 
out an elevation of temperature, often with good appetite, the stools are 
frequent and contain undigested food, because peristalsis is so active that 
the intestinal contents are hurried along with such rapidity that there 
is not time for complete intestinal digestion and absorption. Nothing 
requires nicer discrimination than the use of opium in diarrhcea. It is 
wise to administer it always in a separate prescription, and never in 
composite diarrhceal mixtures. The dose should be regulated according 
to its effect upon the number of stools. Enough is to be given to produce 
a distinct effect — the diminution of pain and the control of exc 
peristalsis — but never enough to check the discharges entirely, or to cause 
stupor. The uncertainty of absorption must also be remembered ; a sec- 
ond full dose should not be given until a sufficient time has elapsed for 
the effect of the first to pass away. For an average child of one year, 
five minims of paregoric, one-fourth minim of the deodorised tincture, or 
one-fourth grain of Dover's powder, may be used as an initial dose, to be 

bed every one, two, or four hours, according to the effect produced. 
Stimulants are often required in severe cases. The prostration is 
great and develops rapidly; frequently almost no food can be assimilated 
for twenty-four or thirty-six hours, while the drain from the discharges 
continues. The general condition of the patient is the best guide as to 
the time for stimulation and the amount required. Old brandy is the 

reparation for general use. An infant a year old may. as a maxi- 
mum, take half an ounce of brandy in twenty-four hours. Stimulants 
should always be diluted with at least eight parts of water, and be given 
in small quantities, at short intervals. 



ACUTE INTESTINAL INDIGESTION AND INTOXICATION. 361 

in cases of extreme prostration, the hot bath, mustard to the extremi- 
ties, and sometimes the mustard pack, are beneficial. When the drain is 
rapid and very great, and in all cases approaching the cholera-infantum 
type, subcutaneous saline injections should be used, in the manner de- 
scribed under Cholera Infantum. 

Finkelstein's " Food Intoxication." — In the chapter upon Difficult 
Feeding we have already referred to this author's classification of cases 
indicating different degrees of nutritional disturbance. The most severe 
form, which by him has been given the name of food intoxication, can 
more properly be discussed in the present chapter. Finkelstein has 
shown that the causative factor in these cases is not bacterial infection 
but a failure in metabolism, and that the condition is aggravated and 
continued by the ingestion of fat and sugar. The various symptoms 
seen in this condition have for some time been well known, but the credit 
belongs to Finkelstein of demonstrating their association in a single 
clinical type. These symptoms do not arise in healthy infants, but in 
those who have previously suffered from minor disturbances of digestion 
and nutrition, usually for some time. Occasionally they may develop 
in the course of some one of the general infectious diseases. 

In a marked case with fully developed symptoms the characteristic 
clinical manifestations of this condition are : ( 1 ) certain nervous symp- 
toms, sometimes those of excitement and delirium, but more frequently 
somnolence, which may be increased to deep stupor or coma; (2) fever, 
usually moderate, but exceptionally very high; (3) disturbed respiration, 
most frequently deep and rapid; (4) diarrhceal stools of great variety, 
no special type being characteristic; (5) very rapid loss of weight; (6) 
a polymorphonuclear leucocytosis, generally between 20,000 and 30,000; 
(7) urine containing albumin and casts; (8) the presence of lactose in 
the urine, if lactose is given in the food; (9) marked general collapse. 
Associated with these characteristic symptoms there may be almost any 
others which are found in a severe intestinal condition. 

With such symptoms as have been described the usual course is rap- 
idly downward with a fatal termination. If the condition is recognised, 
however, and properly treated, many cases recover. The essential treat- 
ment consists in withholding food of every description and giving water 
in as large quantities as can be tolerated without vomiting. With a 
cessation of the most severe symptoms a gradual return to food should 
be made, the first articles allowed being nitrogenous foods, such as broth, 
white of egg, beef juice, and buttermilk, or fat-free milk without addi- 
tional sugar. 

Cholera Infantum. — This is only one type of acute intestinal intoxi- 
cation, yet clinically it differs from the others sufficiently to deserve 
separate consideration. It is not, however, a frequent form. As yet it 
has not been connected with a specific type of intoxication or infection. 



362 DISEASES OF THE DIGESTIVE SYSTEM. 

What it us thai determines the marked and characteristic symptoms in 
cholera infantum is entirely unknown. The symptoms are due primar- 
ily to the effects o\' some poison upon the heart, the nerve-centres, and 
aso-motor aerves of the intestines; secondarily to the abstraction of 
fluid from the various organs and tissues of the body, especially the 
nerve-centres. 

Cholera infantum rarely occurs in an infant previously healthy. As 
a rule, there is some antecedent intestinal disorder. The development 
of the choieriform symptoms is usually very rapid, and a child, who 
perhaps has been regarded as scarcely ill enough to require a physician, 
may be brought, in the course of five or six hours, to death's door. 

Usually there are general symptoms, such as prostration and a stead- 
ily rising temperature, for a few hours before the vomiting and purging, 
or these symptoms may be the first to excite alarm. Vomiting may pre- 
cede diarrhoea, or both may begin simultaneously. The vomiting is very 
frequent. First, whatever food is in the stomach is vomited, then serum 
and mucus, and sometimes there is regurgitation from the small intes- 
tine. If vomiting subsides for a time, it is almost sure to begin anew 
with the taking of food or drink. The stools are frequent, large, and 
fluid, and may occur once or twice an hour. They are of a pale green, 
yellow, or brownish colour in the beginning, but as they become more 
frequent they often lose all colour and are almost entirely serous. The 
sphincter is sometimes so relaxed that small evacuations occur every 
few minutes. The first stools are usually acid, later they are neutral, 
and when serous they are alkaline. In most cases they are odourless; 
in rare instances they are exceedingly offensive. Microscopically the 
stools show large numbers of epithelial cells, some leucocytes, and im- 
mense numbers of bacteria. 

Loss of weight is more rapid than in any other pathological condition 
in childhood; it may be as much as a pound a day. The fontanel is 
depressed, and in rare instances there may be overlapping of the cranial 
bones. The general prostration is great almost from the outset. The 
face, better, perhaps, than any single symptom, indicates what a pro- 
found impression has been made upon the system. The eyes are sunken, 
the feature's sharpened, the angles of the mouth drawn down, and a 
peculiar pallor with an expression of anxiety overspreads the whole 
countenance, which becomes almost Hippocratic. In the early stages 
the nervous symptoms are those of irritation. Later, these symptoms 
give place to dulness, stupor, relaxation, and coma or convulsions. 

The temperature, in my experience, has been invariably elevated, and 
usually in proportion to the severity of the attack. In cases recovering, 
it has generally been from 102° to 103° F., while in fatal cases it has 
risen almost at once to 104° or 105° F., and often shortly before death 
it has reached 100° or even 108° F. Such temperatures may occur 



ACUTE INTESTINAL INDIGESTION AND INTOXICATION. 363 

with a clammy >kin and cold extremities, and are discovered only by the 

thermometer. The pulse is always rapid, and very soon it becomes weak, 
often irregular, and finally almost imperceptible. The respiration is 
irregular and frequent, and may be stertorous. The tongue is generally 
coated, but soon becomes dry and red. and is often protruded. The 
abdomen is generally soft and sunken. There is almost insatiable thirst. 
Everything in the shape of fluids, especially water, is drunk with avid- 
ity, even though vomited as soon as it is swallowed. Very little urine 
is passed, sometimes none at all for twenty-four hours: this depends 
upon the great loss of fluid by the bowels. 

In the fatal cases there is hyperpyrexia, a cold, clammy skin, absence 
of radial pulse, stupor, coma or convulsions, and death. The diarrhoea 
and vomiting may continue until the end, or both may entirely cease for 
some hours before it occurs. The patients may pass into a condition 
resembling the algid stage of epidemic cholera, and die in collapse. In 
other cases, after the first day of very severe symptoms, the discharges 
diminish, but the nervous symptoms become specially prominent. There 
is restlessness and irritability or apathy and stupor. The fontanel is 
sunken; the eyes are half open and covered with a mucous film; respira- 
tion is irregular and superficial, sometimes even Cheyne- Stokes ; the pulse 
is feeble, irregular, or intermittent ; the muscles of the neck drawn back ; 
the abdomen retracted. The temperature is not elevated, but normal or 
subnormal. From this condition recovery may take place or the symp- 
toms may merge into those of ileo-colitis : but much more frequent than 
either of the foregoing is the fatal termination. 

These nervous symptoms are ascribed to cerebral anaemia, cerebral 
hyperemia (venous), oedema of the meninges, thrombosis of the cerebral 
sinuses, and uraemia. Although I have examined the brain in almost 
all my autopsies upon patients dying from diarrhoeal diseases, I have 
never in such cases seen sinus thrombosis, and but rarely oedema. Cere- 
bral hvperaemia was often met with in cases dying in convulsions, but not 
with any regularity otherwise. Xor have my observations upon the 
kidneys confirmed those of Kjellberg, whom most of the writers since 
his day have quoted, as to the great frequency of nephritis. A scanty, 
concentrated, and hence irritating urine is the rule, and a small amount 
of albumin and an occasional hyaline cast not uncommon; but either 
clinical or pathological evidence of a serious amount of nephritis has 
been, in my own experience, extremely rare. 

TV*e can hardly regard either the renal or the cerebral changes as an 
explanation of the nervous symptoms of most of these cases ; they seem 
rather to depend upon impeded circulation due to a thickening of the 
blood, to acute inanition, and general toxaemia. 

An infrequent complication of cholera infantum is sclerema. This 
condition is found associated with muscular contractions, subnormal tern- 



•MM DISEASES OV THE DIGESTIVE SYSTEM. 

perature, and other signs of the most extreme depression. These cases 
are invariably fatal. 

01 the children with true cholera infantum which have come under 
niv notice, fully two-thirds have died. 

Treatment. — Restricting the term cholera infantum to the class of 

described above, all who have seen much of the disease must admit 

that the results of treatment are extremely unsatisfactory, and that the 

severe cases pursue their course but little, if at all, influenced by 

the treatment employed. 

The best view of the treatment will be gained if we keep in mind that 
we are treating cases of poisoning; that the toxic materials cause great 
depression of the heart and the system generally by acting on the nerve- 
centres, and by paralysing the vaso-motor nerves of the intestine. 

The main indications are: (1) to empty the stomach and intestine; 
(2) to neutralise the effect of the poison upon the heart and nervous 
system; (3) to supply fluid to the blood to make up for the very great 
drain of the discharges; (4) to reduce the temperature; (5) to treat 
special symptoms as they arise. 

For the first indication we must rely upon mechanical means — 
stomach-washing and intestinal irrigation — there is no time to wait for 
cathartics. For the second, nothing in my hands has proved so useful 
as the hypodermic use of morphine and atropine. I believe this to be 
more efficient than any other means of treatment we possess. Morphine 
is contraindicated where the purging has ceased or is slight, and where 
there is drowsiness, stupor, or relaxation. The effects of the dose should 
always be carefully watched; a small dose repeated is better than a single 
large dose. For a child a year old, not more than gr. -fa of morphine 
and gr. ^fa of atropine should be the initial dose. It may be repeated 
in an hour unless the desired effects are produced: arrest of the vomit- 
ing and purging (or at least their diminution), improvement in the 
heart's action, and in the nervous symptoms. 

For the third indication the only thing that can be depended upon is 
the injection of normal salt solution into the cellular tissue of the 
abdomen, buttocks, thighs, or back. At least half a pint should be 
used at a time; it should be injected in several places and repeated in 
the course of every twelve hours. A very much larger quantity can 
often be used with advantage. This causes no irritation, and is absorbed 
with surprising rapidity. The injection is made slowly, and the exact 
amount introduced at each time measured. 

For the reduction of temperature, baths should be used. They may 
be continued from ten to thirty minutes, and to be efficient, must be used 
frequently — as often as every hour, if symptoms are threatening. Iced 
cloths or an ice-cap should be applied to the head. Cold-water injections 
are a valuable accessory to the treatment by baths. In most cases noth- 



ACUTE ILEOCOLITIS.— DYSENTERY. 365 

• 

ing should be allowed by the mouth except water. Caffein, camphor, 
and brandy may be used freely. While the use of stimulants is indi- 
cated in every case, their effects are disappointing. Taken by the mouth 
they are almost invariably vomited. If used at all, it should be hypo- 
dermically. During the stage of most acute symptoms, to attempt to 
give food by the mouth is worse than useless. After the stage of violent 
symptoms has subsided and reaction is established, the subsequent man- 
agement in respect to feeding and medication should be the same as in 
the cases considered in the previous chapter. If cerebral symptoms are 
present, opium is to be avoided. For cold extremities and subnormal 
temperature, hot mustard baths should be used to establish reaction, 
mustard paste applied all over the body, and hot-water bags or bottles 
placed about the patient. 



CHAPTER VII. 
DISEASES OF THE INTESTINES.— (Continued.) 

ACUTE ILEO-COLITIS.— DYSENTERY. 

(Entero-colitis; Enteritis; Inflammatory Diarrhcea.) 

The term ileo-colitis is a general one, embracing those forms of 
intestinal disease in which true inflammatory lesions are present. In 
the type of cases described in the previous chapter recovery or death 
takes place before anything more than superficial changes have oc- 
curred, while in ileo-colitis the pathological process continues until 
there have been produced marked lesions, often involving all the walls 
of the intestine. Sometimes it is impossible, by symptoms, to draw a 
line between them. This is especially true of the cases terminating in 
follicular ulceration of the colon. In certain other forms of ileo-colitis 
the evidences of a severe intestinal inflammation are often manifest 
from the very outset. This difference is probably due to a difference in 
the character of the infection. The extent of the lesions depends much 
upon the duration of the process. 

Etiology. — The predisposing causes of ileo-colitis are those common 
to diarrhceal diseases in general, and have already been considered. Al- 
though seen with especial frequency in summer, and in children under 
two years old, it may affect those of any age, and occurs at all seasons. 
Epidemics are not uncommon in the early fall months. While usually 
primary, ileo-colitis often follows infectious diseases, especially measles, 
diphtheria, and broncho-pneumonia. It frequently occurs, in institu- 
tions chiefly, as a terminal infection in infants suffering from extreme 
malnutrition or marasmus. All other forms of intestinal disease are 



366 DISEASES OF THE DIGESTIVE SYSTEM. 

predisposing causes. The question of contagion is unsettled; if at all 
communicable, it is feebly so. When it occurs epidemically a common 
origin scorns more probable than that the disease spreads from one 
patient to another. 

The only bacterium that up to the present time has been shown to 
be capable o\' producing this form of intestinal disease is the B. dysen- 
teries of Shiga. This organism, or, more properly speaking, this group 
of closely allied organisms, has now been found in all parts of the world 
in a sufficient number of cases to establish its etiological connection with 
i loo-col it is. The B. dysenteries was shown by Shiga, in 1898 and 1899, 
to be the cause of epidemic dysentery in Japan. In 1900, Flexner estab- 
lished its association with tropical dysentery in the Philippines, and in 
1902, Duval and Bassett, pupils of Flexner, demonstrated its presence 
in a series of cases of diarrhoea in children at Baltimore. 

In U2 cases of diarrhoea studied in the summer of 1903 this organ- 
ism was present in 270. It was almost invariably found in cases show- 
ing blood and mucus, or much mucus in the stools. Although usually 
the h. dysenteric^ is greatly outnumbered by other organisms, it is not 
uncommon to find it in pure culture. A number of minor differences 
have been found in the bacilli from different cases; there are, however, 
two main groups, the division being made by reason of the difference in 
reaction with litmus mannite ; one group is known as the " true Shiga/' 
or " alkaline " type ; the other, as the " Flexner/' or " acid " type. The 
latter has been most frequently found in the diarrhceal diseases of chil- 
dren in this country, although the true Shiga is occasionally present, and 
in rare cases they may be associated. 

Whether the b. dysenteric is present in normal stools of healthy chil- 
dren is still unsettled. Wollstein at the Babies' Hospital failed to dis- 
cover its presence in the stools of 56 normal infants. The b. dysenterice 
has never been found outside the body ; we are therefore entirely ignorant 
both of its habitat and its mode of entry. There are grounds for believ- 
ing that it appears at times among the saprophytic bacteria of the intes- 
tinal contents. 

The role played by other bacteria, especially the streptococcus, in the 
production of the deeper lesions of the intestine may be an important 
one. This appears, however, to be rather in the nature of a secondary 
invasion. 

Lesions. — Tt is surprising that, so far as is known, a single specific 

can excite such a variety of lesions. The nature of the anatomical 

change- apparently depends upon other factors, such as the intensity 

of the infection, the local resistance, and still more upon the duration 

of the disei 

The nature of the lesions in ileo-colitis differs greatly, but their 
position is quite constant: they affect the lower ileum and the colon. 



ACUTE ILEO-COLITIS.— DYSENTERY. 367 

In about half the cases only the colon is affected. The lesions of the 
ileum are usually limited to the lower two or three feet. 

The frequency with which the different varieties of ileo-colitis were 
found in eighty-two of my own autopsies was as follows : 

Follicular ulceration 36 

Catarrhal inflammation 26 

Catarrhal inflammation with superficial ulceration 6 

Membranous inflammation 14 

82 

Acute Catarrhal Ileo-colitis. — In the milder cases there are 
changes in the epithelium and infiltration of the mucosa. In the severer 
cases the submucosa is involved, and the infiltration of the mucosa may be 
so great as to lead to necrosis and the formation of ulcers. 

Gi'oss Appearances. — While the lower ileum and the colon are most 
seriously affected, it is not uncommon to find quite marked changes in a 
considerable portion of the small intestine, and even in the stomach. In 
the cases of short duration, the lesions are sometimes more marked in the 
small intestine than in the colon. The stomach contains undigested food, 
and mucus which is commonly stained a dark-brown colour. It may be 
dilated or contracted. The mucous membrane is pale or congested; if 
the latter, it is usually in patches, and more about the pyloric orifice. 
The intestinal contents are generally green in colour, and thin. The 
mucous membrane is often coated with tenacious mucus. The small in- 
testine is distended with gas, the large intestine nearly empty, except the 
transverse colon. The mucous membrane may appear somewhat swollen. 
In the small intestine there are occasionally seen swelling and oedema of 
the villi, so that they project abnormally and give a plush-like appear- 
ance. Congestion is a constant feature, and it may be simply upon the 
folds of the mucous membrane, or about the solitary follicles, or it may 
be intense and involve the whole intestine for some distance. Small 
hemorrhagic areas are often seen here and there, widely scattered. In 
the most severe cases there are marked thickening and uniform conges- 
tion, and the appearance is sometimes much like that seen in membran- 
ous inflammation. The solitar}^ follicles throughout the colon are usu- 
ally swollen, projecting above the mucous membrane and about the size 
of a pin's head. Peyer's patches may be normal, or they may be swollen 
and congested, with other evidences of catarrhal inflammation in the 
surrounding mucous membrane, or, more rarely, they may be involved 
when the rest of the mucosa appears healthy. The same is true of the 
lymph nodules of the small intestine. The lymph nodes of the mesentery 
are usually swollen and acutely congested, but they may appear normal. 

Microscopical Appearances. — In interpreting the changes found in 
the mucosa, the same precautions must be observed as previously stated. 



368 



DISEASES OF THE DIGESTIVE SYSTEM. 



There is usually loss of the superficial epithelium and of that lining 
the tabular glands at their orifices. Upon the surface of the mucosa and 
within the tubular glands, line granukr matter is seen derived from the 
broken-down epithelium. The goblet cells are distended with mucus, 
and do not stain clearly. The lumen of the tubular glands is narrowed 
from pressure due to the swelling of the lymphoid tissue which separates 
them, which is partly from oedema, and partly from cell infiltration 
(Fig. 54). A thick layer of mucus and round cells, adhering closely 
to the surface, may resemble a pseudo-membrane (Fig. 55). In fatal 
of moderate severity the superficial portion of the mucosa is in- 
filtrated with round cells and crowded with bacteria of many kinds, the 
depth to which this infiltration extends depending upon the severity 
and duration of the process. In very severe cases there is found a dense 








_lif|Sl§|ggiiEi!lc 



Fig. 54. — Acute Catarrhal Inflammation of the Ileum. At the left is seen the edge 
of a Peyer's patch (P) greatly swollen. The most striking feature of the lesion is 
the loss of the superficial epithelium, which is shown in all parts of the specimen. 
The significance of this depends upon the fact that the autopsy was made but two 
hours after death. At several points, F, F, the tubular follicles have loosened and 
fallen out. The mucosa, A, is slightly infiltrated with cells, especially near the Peyer's 
patch. The submucosa, C, and muscular coats, D, E, are normal. V, V, are small 
veins. History. — Infant, nine months old, previously healthy; sick three days with 
severe intestinal symptoms; temperature, 103° to 105° F. Autopsy. — Acute catarrhal 
inflammation of ileum and colon; Peyer's patches red and swollen. The specimen is 
taken from the lower ileum. The superficial character of the lesion is chiefly due to 
the short duration of the process. 

infiltration of the mucosa and of the submucosa also, which in places 
extends quite to the muscular coat. These cases closely resemble those of 
t be membranous variety, lacking only the exudation of fibrin. The lymph 
nodules of the colon are swollen to a greater or less degree, chiefly from 
an increase in the number of lymphoid cells. This swelling may be the 
most prominent feature of the lesion. If the process is sufficiently pro- 
longed, the lymph nodules may break down and ulcerate. The changes in 
the lymph nodules of the small intestine and in Peyer's patches are sim- 
ilar to those seen in the colon, but are less marked, and frequently absent 
altogether. Ulceration in Peyer's patches is extremely rare. 



PLATE YUL 



A - 




Extensive Superficial Ulceration of the Colon. 

Female child nine months old ; symptoms of acute ileo-colitis of fifteen days' dura- 
tion; temperature, 101° to 104*5° F., and from six to eight stools daily — thin, green, 
and yellow, but no blood. 

Extensive ulceration throughout the colon, most marked in descending portion, 
from which specimen is taken. 

A A are small circular ulcers ; B B, larger ones from coalescence of several of 
these ; C C, large areas of ulceration, the mucous membrane being almost entirely 
destroyed. 



ACUTE ILEO-COLITIS.— DYSENTERY. 



369 



The small veins and capillaries of the mucosa and submucosa are 
usually distended with blood ; small extravasations are very common, and 
occasionally larger ones are seen. 

Catarrhal inflammation, except in its very severe form, which is not 
frequent, causes no lesions that can not readily be repaired. The most 




Fig. 55. — Acute Catarrhal Inflammation of the Ileum; Severe Form. The mucosa, 
C, is everywhere densely infiltrated with round cells, compressing the tubular follicles, 
and in places, L, L, almost effacing them. Upon the surface of the mucosa is a thick 
layer of cells and mucus. Beneath this the epithelial arches, B, B, covering the villi 
can be seen. The lesions are almost entirely of the mucosa. The only changes in 
the submucosa, E, are groups of cells about the small blood-vessels, V, V. History. — 
Infant six months old; moderate diarrhoea twelve days; severe symptoms with high 
temperature for six days. There was intense inflammation of the entire colon and 
lower three feet of the ileum. Intestine greatly congested and thickened. Specimen 
is from the ileum. 



persistent change is usually the swelling of the lymph nodules, which 
may last a long time, and appears to be an important factor in the 
tendency to relapses and recurring attacks. If there is a continuance 
of the exciting cause, or the patient's constitution is feeble, the process 
may become chronic. 

Catarrhal Inflammation with Superficial Ulceration. — In 
the most severe form of catarrhal inflammation which does not prove 
fatal in the earlier stages, extensive ulceration occasionally takes place; 
usually these ulcers are seen throughout the entire colon, and occasion- 
ally a few are found in the lower ileum. They generally begin in the 
mucosa overlying the lymph nodules, and while they have a wide super- 
ficial area, they do not extend deeper than the mucosa. The small 
ulcers are circular and usually show at the centre a small granular body 
— the lymph nodule. The larger ulcers result from the coalescence of 
several small ones, and are irregular in shape. They may be two or 
three inches in diameter. Sometimes for a considerable distance a large 
25 



370 



DISEASES OF THE DIGESTIVE SYSTEM. 



pari o( the mucosa may be destroyed. Often the entire surface presents 
a worm-eaten appearance (Plate VIII), On microscopical examination 
there is soon, in the greater pari of the ulcer, complete destruction of 
the mucosa, the submucosa being densely packed with round cells quite 
to the muscular coat. 

Inflammation of the Lymph Nodules with Ulceration (fol- 
licular ulceration). — Follicular ulcers are found at autopsy in about one- 
third of the cases dying from diarrhceal diseases. They are rarely seen 




Fig. 56. — Lymph Nodule of the Colon in the Early Stage of Ulceration — Follicu- 
lar Ulcer. The nodule, F, is much enlarged, and is breaking down and discharging 
into the intestine. The other changes are not marked. The superficial epithelium 
is gone; the mucosa, A, shows a slight increase of cells, and in the submucosa, C, are 
nests of cells about the small vessels, V, V. History. — Delicate child, thirteen months 
old; slight diarrhoea four weeks; severe symptoms five days. The colon was filled 
with ulcers one-twelfth of an inch in diameter, one of which is shown in the illustration. 

in those which have lasted less than a week, and not often before the 
middle of the second week. The average duration of the disease in 
these cases is about three weeks. 

In thirty-six cases in which follicular ulcers were found at autopsy, 
they were present in the small intestine alone in but three cases; in the 
small intestine and in the colon in six cases; in the remaining twenty- 
seven they were present only in the colon. When in the small intestine 
they were seen only in the lower ileum. Ulceration was seen a few times 
in one or two of the nodules of a Peyer's patch. Ulceration of the large in- 
testine involved the whole colon in about half the cases; while in the re- 
mainder the process was limited to its lower portion. The deepest and also 
the largest ulcers were usually in the descending colon and sigmoid flexure. 



PLATE IX. 




Deep Follicular Ulcers of the Colon. 

A delicate child, fourteen months old. sick twelve days : stools green, yellow, brown, 
and watery: no blood : temperature, 100 : to 101° F. 

The small intestine was normal ; ulcers throughout colon. The specimen is from 
descending colon: the ulcers are deep, and most of them extend to the muscular coat. 
(For microscopical appearance, see Fig. 68.) 





ACUTE ILEO-COLITIS— DYSENTERY. 371 

In the early stage these ulcers appear as tiny excavations at the sum- 
mit of the prominent lymph nodules. Later, the whole nodule may be 
destroyed, and a small round ulcer is formed from one-twelfth to one- 
fourth of an inch in diameter (Plate IX). These are quite deep and 
have overhanging edges ; when closely set they give the intestine a sieve- 
like appearance. By the coalescence of several of them, larger ulcers 
may form which are an inch or more in diameter. At the bottom of 
these larger ones the transverse striae of the circular muscular coat are 
often plainly seen. I have never known them to cause perforation. 

Microscopical Appearances. — The lymph nodules are swollen, prin- 
cipally from the accumulation within them of round cells. This is fol- 
lowed by softening, which usually begins at the summit of the nodule 
and extends downward; the reticulum breaks down, and the cellular 
contents escape into the intestine (Fig. 56). Softening may begin at 
the centre of the nodule, which ruptures like an abscess. The destruc- 






Fig. 57. — Deep Follicular Ulcer of the Colon. A deep ulcer is shown at F, a smaller 
one at F' . The separation of the mucosa at H is accidental. There is no trace of the 
lymph nodule from which the large ulcer had its origin. The destructive process has 
extended laterally in the submucosa, C, and the mucqsa, A, is falling in to fill up the 
space. In the vicinity of the ulcers, the submucosa is densely infiltrated with round 
cells, L", L", which also are seen in the lymph spaces between the bundles of circular 
muscular fibres, L', U , and some are seen in the longitudinal muscular coat, L, L. 
History. — Thirteen months old, delicate; continuous diarrhocal symptoms for three 
weeks. Ulcers found throughout the colon, the largest, one-half an inch in diameter. 
The illustration shows one of the small ones like those in Plate IX. 

tion of the whole nodule leaves a cavity, which is the follicular ulcer. 
At first the ulcer corresponds in size to the nodule, but infiltration of 
the adjacent tissue soon takes place, which may become necrotic. In 
this way the ulcer extends chiefly in the submucous coat. The lesion is 
never limited to the lymph nodules ; but the extent of the other changes 
found depends upon the severity and the duration of the process. In 
cases dying after an illness of a week or ten days, we usually find only 
moderate changes in the mucosa, and in the submucosa a slight infiltra- 



DISEASES OF THE DIGESTIVE SYSTEM. 

t ion of round rolls, especially about the small blood-vessels (Fig. 56, 
l l). In those which have lasted throe or four weeks the ulcers are 
deeper, and all the structures of the intestine in their neighbourhood are 
usually involved (Fig. 57). The mucosa is densely packed with round 
cells, as arc also all the tissues in the vicinity of the ulcers; even the mus- 
cular coat may he infiltrated. The ulcers, however, rarely extend deeper 
than the circular layer. 

Follicular ulceration of the intestine in infancy usually terminates 
fatally if the process is an extensive one. In less severe cases recovery 
may take place, the ulcers healing by granulation and cicatrisation in the 
course of from four to eight weeks. 

Acute Membranous Ileo-colitis. — This is the most severe form 
of intestinal inflammation seen among children. The process differs 
quite materially from that described as occurring among adults. In 
only one of my own cases was it associated with membranous inflamma- 
tion of any other mucous membrane, in that case with membranous gas- 
tritis. The most frequent type of membranous colitis is that with 
severe acute symptoms, both constitutional and local, with a duration 
of from six to fourteen days. In young infants its symptoms and 
course are very irregular, and it may be found at autopsy when no seri- 
ous intestinal lesion has been suspected. 

Gross Appearances. — There is visible to the naked eye usually very 
little pseudo-membrane and no deep sloughing. The lesion affects the 
last two or three feet of the ileum and the entire colon, sometimes only 
the colon. It is exceedingly rare to meet with any marked lesions higher 
in the small intestine. The most marked changes are near the ileo-caecal 
valve or in the sigmoid flexure and the rectum. In the ileum they may 
be quite as severe as in the colon (Plate X). The intestinal wall is 
firm and stiff, and is two or three times its normal thickness. It is not 
thrown into deep folds, as is the healthy intestine when empty. It is 
very rare to find false membrane that can be stripped off in patches of 
any considerable size. When membrane exists, the colour is a yellowish 
or grayish green, and the surface is often fissured, giving a lobulated 
appearance. In the parts where no pseudo-membrane can be seen, the 
surface is usually of an intense red colour and is rough and granular, in 
striking contrast to the normal glistening appearance. Here and there 
small extravasations of blood may be seen. In the regions most affected, the 
normal structures of the mucous membrane — the villi, Peyer's patches, 
and solitary follicles — can not be distinguished. In a single instance I 
found an exudation of fibrin on the peritoneal surface of the intestine for 
;i Bhort distance. Except in the lower ileum the small intestine shows 
uo constant changes, and none are usually found in the stomach. 

Microscopical Changes. — These (Fig. 58) are much more uniform 
than the gross appearances. The most characteristic feature is the exu- 



PLATE X. 




Membranous Inflammation of the Ileum. 

A delicate child, eleven months old ; mild diarrhoea for two weeks without fever ; 
acute severe symptoms for twelve days ; temperature, 100° to 102*5° F. ; green and 
mucous stools ; no blood. 

The lesions involved the last foot of ileum and entire colon. Specimen is from 
lower ileum, and shows the abrupt termination of the lesion ; the upper part shows 
normal small intestine ; A is a Peyer's patch ; B is the inflamed part of the intestine ; 
it has a rough granular appearance and is much thickened. 



ACUTE ILEOCOLITIS.— DYSENTERY. 



373 



elation of fibrin, which forms a distinct pseudo-membrane upon the 
surface of the intestine; it may infiltrate the mucosa, and even the sub- 
mucosa. Fibrin is seen under the microscope in parts of the specimen, 
which to the naked eye show no distinct pseudo-membrane, but only a 
granular appearance. In rare cases a fibrinous exudation may be found 
upon the peritoneal covering of the intestine. The pseudo-membrane is 
made up of a fibrinous network containing small round cells, some red 




■ji/p. #v#' 1 ^¥ S^^^iRlip||lJ| 










Fig. 58. — Membranous Inflammation of the Colon. The intestine is covered with 
a pseudo-membrane, M, which is composed chiefly of granular fibrin; the mucosa, 
A, is densely packed with round cells, and the tubular follicles have almost dis- 
appeared, traces only being left at T, T. The submucosa, C, is greatly thickened, 
partly from cells, but chiefly from fibrin, which with a high power is seen to be every- 
where in this coat, as well as the mucosa. Nests of cells are seen in the muscular 
coats at L, L. At F is a lymph nodule covered by pseudo-membrane, but breaking 
down at its centre. V, V, are small blood-vessels with nests of cells about them. 
History. — Fourteen months old; ill nine days; temperature 101° to 105° F. ; all stools 
containing blood. Lesions found throughout colon and in lower ileum. Intestine 
greatly thickened. Specimen is from ascending colon, where lesion was especially 
severe. 



blood-cells, and numerous bacteria. The mucosa, and usually the sub- 
mucosa, are densely infiltrated with small round cells, which in places 
may be so numerous as to efface the normal elements of the intestine. 
The tubular follicles are in some places quite destroyed, not a vestige of 
them remaining. In other places they are compressed and distorted by 
the accumulation of cells. The great thickening of the intestine is due 
partly to the cell infiltration, partly to the fibrinous exudation, and 
partly to oedema. All the blood-vessels, both in the mucosa and sub- 
mucosa, are gorged with blood, and many small extravasations are seen. 



;;;i DISEASES OF THE DIGESTIVE SYSTEM. 

A necrotic process with the formation of deep ulcers 1 have never seen 
ated with membranous colitis. 

Associated Lesions of [leo-colitis. — The most important one is 
broncho-pneumonia. It is found in quite a large proportion of the pro- 
tracted cases, and not infrequently it is the cause of death. I think it is 
seldom due to an infection from the intestine, although such a thing is 
possible in septicemic cases, h occurs rather as it does in any other 
protracted exhausting disease. In a study of sixty cases, Spiegelberg 
did not find bacteria in the pulmonary capillaries, and he regards in- 
fection through the blood as not yet proved. Pulmonary tuberculosis 
is not infrequently met with in hospital cases, having no relation to the 
intestinal disease. Peritonitis is infrequent. I have met with it but 
oiue or twice, and then it was localised and of the plastic variety. In- 
flammations of the other serous membranes — pleurisy, pericarditis, and 
meningitis — are all very rare. 

The renal lesions of ileo-colitis have been the subject of considerable 
discussion, some observers holding that nephritis is a frequent compli- 
cation of the severer forms of diarrhoea, while others have held it to be 
rare. The lesions I have usually found in my own cases coincide with 
those described by others, and consist in marked degeneration of the 
epithelium of the tubes with but few glomerular or interstitial changes. 
In three or four instances only have I found well-marked lesions of acute 
diffuse nephritis at autops}', or seen its symptoms clinically. I believe 
it to be a very infrequent though sometimes a most serious complica- 
tion. The lesions mentioned as usually present are properly classed 
as acute degeneration rather than as inflammation of the kidney. Its 
causes are chiefly the irritation of toxins, intensified no doubt by the 
concentration of the urine. Degenerative changes may be found also 
in the heart muscle, the liver, spleen, and even in the central nervous 
system. 

Considerable attention has been given to a study of the blood in 
intestinal inflammations, to determine how frequently and in what 
circumstances a general blood infection (septicaemia) from the intes- 
tines occurs. In the great majority of the cases studied under proper 
precautions the blood is sterile. 

Symptoms. — (1) Catarrhal Cases of Moderate Severity. — The onset is 
usually sudden, often with vomiting, and for twelve, sometimes twenty- 
four hours the symptoms may be those of acute indigestion: vomiting, 
pain, fever, and frequent, thin, green or yellow stools, which are partly 
faecal and contain undigested food. Later the discharges contain blood 
and mucus, are often preceded by pain and accompanied by tenesmus. 
The stools are very frequent, often every half hour, and proportionately, 
small, sometimes less than a tablespoonful being found upon the nap- 
kin after severe straining efforts. The mucus may be clear and jelly- 



ACUTE [LEO-COLITIS. DYSENTERY. 



375 



like, or it may be mixed with faecal matter. Blood is seen in some cases 
in almost every stool, but rarely in clots, usually streaking the mucus. 
These stools are almost odourless. After two or three days the blood 
usually disappears, or is seen only as traces in an occasional stool ; but 
mucus is still present in large quantities. The colour of the discharges 
now becomes dark brown or brownish-green. Prolapsus ani is frequent, 
and may occur with nearly every stool. Abdominal pain is present, and 
is often quite intense just before the stool; and frequently there is ten- 
derness along the colon. For the first twenty-four hours the tempera- 
ture is usually high, from 102° to 104° F. During the greater part of 



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Fig. 59. — Weight Curve Showing Loss from Ileo-colitis. Well-nourished infant; 
attack of measles at A (fortieth week), followed by ileo-colitis, which though not 
severe continued with exacerbations during September and October. At B all 
symptoms had disappeared except occasional mucus in the stools. Rapid improve- 
ment from this time, which was continued during the winter, the child being sent 
to a warm climate; it was, however, five and a half months before the weight reached 
the normal average line. 



the attack it ranges from 99° to 102° F. There is considerable prostra- 
tion; the loss in weight is usually marked and continuous; appetite is 
lost; the tongue is coated and the general appearance of the children in- 
dicates serious illness, although no really grave symptoms are present. 
Convalescence is always slow, and it may be months before the lost 
weight is regained (Fig. 59). 

In the milder cases the symptoms point to inflammation of the lower 
part of the colon only. The constitutional symptoms are not at all 
marked. The temperature may not be above 101° F. ; the tongue may 
remain clean and the appetite good; the child may be bright and active, 
and hardly seem at all ill, and yet have from six to eight small mucous 
and bloody stools a day. 

The duration of the acute symptoms is usually about a week, and 
yet in such cases, even though the child was previously in good condition 



376 Pisi \>l> OF THE DIGESTIVE SYSTEM. 

and property treated, recovery is slow. The first symptom of improve- 
ment is generally the disappearance of blood from the stools, which at 
tame time become loss frequent, and the pain and tenesmus cease. 
Gradually the stools assume more of a faecal character, but mucus is 
likely te persist for two or three weeks; it may be seen in all stools, or 
only occasionally. In some cases both the mucus and blood disappear 
and the stools become thin, brown, or green, like those of an ordinary 
diarrhoea. Although the early stage of very acute symptoms may last 
but a few days, if there is a continuance for three or four weeks of the 
brown, mucous stools, with emaciation and slight fever, ulceration is 
probably present This is likely to occur if the child is in poor condition, 
if its surroundings are bad, or if it is improperly treated at the outset. 
Relapses are readily excited, but cases like the above are rarely fatal 
except in delicate infants. This is the most common form of ileo-colitis 
which terminates in recovery. 

('2) The Severe Catarrhal Form. — This form of ileo-colitis, like that 
just described, is usually primary. The symptoms closely resemble those 
of the membranous variety, and a diagnosis from it is to be made only 
by the absence of pseudo-membrane from the stools. The most rapid 
case 1 have seen lasted only three days, but the usual duration is from 
one to two weeks. The temperature is steadily high; the stools continue 
very frequent and generally contain blood; there is great prostration, 
dry tongue, sordes on the lips and teeth, and prominent nervous symp- 
toms. Death usually occurs from exhaustion and profound sepsis while 
the acute symptoms are at their height. If the patient survives this 
stage, the case may drag on for four or five weeks, very much like one 
of follicular ulceration, and then terminate in recovery or in death from 
slow asthenia, broncho-pneumonia, or from an acute exacerbation of 
the intestinal symptoms. The autopsy in such cases usually reveals the 
presence of artificial ulcers. If recovery is to be the outcome, after 
the symptoms have been nearly stationary for a long time, there is seen 
a gradual improvement first in the general and then in the local con- 
ditions. Convalescence is very slow, often interrupted by relapses, and 
it may be months belore the patient is quite well. In some cases the 
child never regains his former vigour. 

(3) Follicular Ulceration — Ulcerative Inflammation of the Nodules. 
— Follicular ulceration is often preceded by other forms of intestinal 
disease. It is not very frequently met with in infants under six months 
of age. The great majority of those affected are in poor condition at 
the time of the attack. 

To understand the symptoms of these cases, it must be remembered 
that follicular ulceration is a terminal process following other forms of 
diarrhoea. It may be preceded by one or more acute attacks, or by a 
protracted subacute attack. On account of the feeble resistance of the 



ACUTE ILEO-COL1TLS.— DYSENTERY. 



377 



child or the continuance of the exciting cause, the pathological process 
gradually extends to the lymph nodules of the intestine, chiefly the 
colon, which, as already described, pass successively through the stages 
of swelling, softening, and ulceration. The onset of the illness may 
therefore be abrupt, with vomiting and high fever; or gradual, without 
vomiting and with very little fever. The patient may be ill for a week 
before the exact type which the disease is assuming can be positively 
determined. It is not possible to mark the transition from acute gastro- 
enteric intoxication to follicular ileo-colitis. Usually the latter may be 
assumed to exist whenever, after a very acute onset, there is a continued 
temperature, and when the stools habitually contain large quantities of 
mucus without blood. 



DAY 




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Fig. 60. 



-Temperature Chart of Ileo-colitis, Fatal on Thirty-fourth Day. 
Autopsy showed follicular ulcers throughout the colon. 



Vomiting is not a feature of these cases ; but it is often present at the 
onset. Throughout the attack it is easily excited by injudicious feeding 
or medication. The temperature is seldom high, except at first ; its usual 
range is from 99° to 101° F. ; toward the close, even of fatal cases, it may 
be scarcely above the normal. The accompanying chart (Fig. 60) is a 
very good illustration of the course of the temperature in cases begin- 
ning abruptly and ending fatally. 

The stools are seldom very frequent, the number being from four 
to eight a day. The most constant feature is the presence of mucus, 
which is mixed with the stools and usually abundant. Blood is not gen- 
erally present, and a large amount of blood is extremely rare. It was 
absent entirely in more than half of my cases in which the diagnosis 
was confirmed by autopsy. A small quantity of blood early in the attack 
is not uncommon, depending here upon congestion. Large haemorrhages 
from ulcers I have never seen. The colour of the stools is most fre- 
quently dark green or brown. Fluid stools are seen only during exacerba- 
tions. The odour is usually offensive, particularly in protracted cases. 
The microscope shows epithelial cells in great numbers, and very often 
an abundance of small round cells, which may be looked upon as the 
most constant sign of ulceration. 



378 DISEASES OF THE DIGESTIVE SYSTEM. 

The failure in nutrition and steady loss in weighl arc very constant 
in thee As emaciation goes on, the skin hangs in loose folds on 

the thighs; it becomes dry and scaly and loses its elasticity, and occa- 
sionally small petechial spots are seen upon the abdomen. The skin over 
the buttocks becomes excoriated, and bed-sores form over the heels, the 
sacrum, or the occiput. The abdomen may be moderately distended, or 
it may be relaxed and soft. Tenderness is not usually present. The 
appetite is lost, and in most cases great difficulty is experienced in getting 
children to take a proper amount of nourishment. Continued aversion 
to food is an unfavourable symptom. Occasionally, when there is fever, 
fluids are taken eagerly. A returning appetite is always an encouraging 
sign. The mouth is often dry, the tongue coated, sometimes dry and 
brown ; there may be sordes upon the lips and teeth. Superficial ulcers 
form upon the mucous membrane of the mouth, and often thrush is 
seen. The urine is usually diminished, high-coloured, and loaded with 
urates. Albumin and casts are rarely present. In only two or three 
cases have I seen nephritis severe enough to be a factor in the result. 
Tenesmus and prolapsus ani are uncommon. 

The average duration of the fatal cases is about three weeks; their 
course is often marked by exacerbations and remissions. If recovery 
takes place, convalescence is always very slow and relapses are easily 
excited. 

Very few of these cases recover completely. Even those who survive 
the primary illness are likely to suffer from intestinal symptoms for 
many months. Fatal relapses are often brought on by injudicious feed- 
ing when the children are apparently almost well. The general health 
is usually so undermined that the patients continue to suffer from all the 
symptoms of malnutrition, and ultimately succumb to an attack of some 
intercurrent acute disease. 

The diagnosis of ulceration is to be made from the case as a whole 
rather than from any special symptoms. If a delicate infant, who has 
previously been prone to diarrhceal attacks, has green mucous stools with 
low fever, and these symptoms continue with unabated severity for ten 
or twelve days, ulceration is probable. If such symptoms continue for 
three or four weeks with steadily failing strength and loss of weight, the 
diagnosis is almost certain. If, on the contrary, after three or four days 
of acute symptoms there is improvement in the stools and occasionally 
some which are quite; fa j cal in character, even though it may be a week 
or more before the mucus disappears, we may be quite certain that no 
ulcers have formed. 

(4) The Membranous Form. — This is the gravest form of inflamma- 
tion of the intestines seen in children, and its symptoms are more often 
obscure than are those of any other variety. This is particularly true 
when it affects young infants. There may be at the onset and through- 



ACUTE ILEO-COLTTIS.— DYSENTERY. 



379 



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out the course of the disease severe local and constitutional symptoms; 
or with well-marked constitutional symptoms, the local symptoms may 
be slight or of very doubtful character, so that it is often mistaken for 
some other disease. 

In the first form it closely resembles the most severe cases of catar- 
rhal inflammation. The disease begins abruptly, with vomiting, high 
temperature, and several large, fluid stools. The vomiting does not 
often continue after the first twenty-four hours. The temperature is at 
first from 102° to 105° F., and its course may be steadily high (Fig. 61), 
or remittent. The abdomen is often 
tender and sometimes swollen. There 
is severe pain, and at times tenesmus, 
with prolapse of the rectum. This is 
intensely congested, and sometimes 
shows patches of pseudo-membrane 
upon its surface, thus establishing 
the diagnosis. 

The stools often resemble those 
of the catarrhal variety, except that 
blood is more constantly present and 
usually more abundant, but the only 
positive point of difference is the 
presence of shreds or flakes of pseudo- 
membrane. If the stools are thor- 
oughly washed with water these may be seen as small gray opaque 
masses, which are then easily distinguished from the transparent mucus. 
Large shreds of membrane are seldom seen in children. Both blood and 
mucus sometimes disappear from the stools, which may consist only of 
dirty water. Under the microscope there may be seen epithelial cells, 
red blood-cells, and round cells in great numbers. 

The presence of cerebral symptoms in these cases of membranous 
ileo-colitis may lead to great obscurity in the diagnosis. This is most 
frequently true at the onset. There may be high temperature, great 
prostration, vomiting, stupor, delirium, and even convulsions; and such 
symptoms may for two or three days completely mask the intestinal con- 
dition. As the case progresses, however, the intestinal symptoms come 
more and more into prominence, and the cerebral symptoms usually sub- 
side. But sometimes this is not the case. I once saw a case closely 
watched for two weeks by three physicians of large experience, who were 
agreed in the diagnosis of a cerebral lesion, but not as to its nature, 
which showed at autopsy only the lesions of membranous colitis. There 
was a continuous but irregular fever, stupor, retracted abdomen, opis- 
thotonus, unequal pupils, and at times irregular respiration. Two or 
three days before death the first blood appeared in the stools, and at 



Fig. 61. — Temperature Chart of 
Membranous Colitis; Fatal. 



380 



DISEASES OF THE DIGESTIVE SYSTEM. 



me time, daring extensive rectal prolapse, a false membrane was 

Membranous colitis is also obscure when it afreets young infants. 
Kverv year a number of these rases are seen at the Babies' Hospital. 
The prominent symptoms are: rather high, continuous temperature, 
usually ranging between 101° and 104° F., but following no distinct 
curve (Pig. 62) : wasting, which is not rapid but progressive; frequent 



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Fig. 62. — Temperature Chart of Membranous Colitis. Infant fourteen months 
old, Babies' Hospital. Symptoms for the first two weeks obscure, suggesting first 
pneumonia, afterward meningitis. Intestinal symptoms for the last two weeks only, 
never very severe; stools four to six daily, generally green, thin, with much mucus at 
times, and once or twice traces of blood. Culture four days before death showed 
streptococci and colon bacilli. Autopsy: No lesion of importance except mem- 
branous colitis involving entire colon ; a slight catarrhal enteritis. 



stools, which have no constant or striking characteristics. They are 
usually thin, yellow or greenish in colour, often containing no mucus or 
blood. Occasionally for a day the stools may be almost normal in ap- 
pearance. In number they average five or six a day, but often for days 
only two or three. Outside of a hospital where autopsies are regularly 
made these cases are usually overlooked and considered as obscure pneu- 
monia, tuberculosis, septicaemia, typhoid, etc. 

The duration of membranous ileo-colitis is usually from one to three 
weeks. Death takes place from sepsis, exhaustion, or from complica- 
tions. It is probable that almost every case of the severity described 
terminates fatally when it occurs in an infant. In older children the 
prognosis is much better as to life, but in them the acute attack may 
be followed by the chronic form of the disease. 

Diagnosis. — Ileo-colitis is to be distinguished chiefly from typhoid 
fever, intussusception, and meningitis. Typhoid is distinguished by the 
slower invasion, more constant temperature, enlargement of the spleen, 
tympanites, and most of all by the Widal reaction and the eruption. 
Acute colitis should not be confounded with intussusception; yet the 
records of intussusception show that a very large proportion of the cases 
regarded in the beginning as cases of dysentery. In intussuscep- 
tion, although we have a sudden onset with acute pain, tenesmus, vomit- 
ing, and marked prostration, there is rarely fever. The later symptoms 



ACUTE ILEO-COLITIS.— DYSENTERY. 3g 1 

— absolute constipation, tumour, stercoraceous vomiting, and collapse — 
have nothing in common with colitis. The membranous form may be 
confounded with meningitis, and in some cases a differential diagnosis 
is impossible except by lumbar puncture. Marked diarrhoea, even 
though the stools are not characteristic, should always make one doubt 
meningitis. 

A diagnosis between the different varieties of ileo-colitis is not always 
possible. Follicular ulceration is distinguished by its lower temperature, 
rather subacute course, infrequency of blood in the stools, and by the 
fact that it is usually preceded by diarrhceal attacks which are often 
prolonged. 

In the catarrhal form, the symptoms of an acute inflammation of 
the colon are usually manifest from the outset — bloody stools, pain, 
tenderness, tenesmus, and fever. In the membranous variety such symp- 
toms are sometimes seen; but, as a rule, the local symptoms are less 
pronounced, while the constitutional symptoms, especially those relating 
to the nervous system, are usually marked. The course is usually shorter 
and more intense than in the other forms. 

An agglutination reaction of the B. dysenterice with the serum of 
affected children is usually present. But for general use in diagnosis 
this is not of great assistance. It is subject to considerable variation. 
Moreover, it is seldom present until the end of the first week of the dis- 
ease, by which time the nature of the attack is evident by clinical symp- 
toms. Agglutination in the higher dilutions is seen only with the par- 
ticular type of organism with which the infant is infected. 

Prognosis. — The younger the patient the worse the outlook. The 
prognosis is rendered unfavourable by extreme summer heat and by 
prolonged previous attacks of intestinal disturbance. The outlook is 
worse in secondary than in primary cases. In a given case bad prog- 
nostic symptoms are: continuous high temperature, the persistence of 
much blood in the stools, and severe nervous symptoms. The prognosis 
is always worse in institutions than in private practice. 

Prophylaxis. — What has been said regarding general prophylaxis in 
the previous chapter, applies equally well to cases of ileo-colitis. 

' Special emphasis should be placed upon the necessity of energetic 
early treatment of all the milder forms of diarrhoea, and particularly 
the cases of acute intestinal indigestion and intoxication, in order that 
the process may be arrested before serious anatomical changes have taken 
place. Equal stress should be laid upon the importance of prompt and 
intelligent treatment at the very beginning of the cases with a sudden 
onset. 

Hygienic Treatment. — The general plan recommended in the pre- 
vious chapter should be followed here. A change of air is desirable for 
most cases as soon as the acute inflammatory symptoms have subsided. 



DISEASES OF THE DIGESTIVE SYSTEM. 

In the protracted cases which drag on a subacute course, this change 
will often do more than anything else. Plenty of fresh air is necessary 
in all cases. The indications for bathing are the same as in other cases 
of acute diarrhoea. It is undesirable to crowd these patients in institu- 
tions, as they always do better when separated. 

The diet during the acute stage should be the same as in other forms 
of acute diarrhoea. In the protracted cases the diet presents great dif- 
ficulties, as the children have little or no appetite, and soon come to 
refuse everything in the shape of food that is offered. In infancy, in 
the early stage only, barley or rice water should be given. In the later 
stage the articles which are most to be depended upon are skimmed 
milk, which has been sterilised, buttermilk which should be diluted 
according to the conditions present, and animal broths. Especially to 
be avoided, not only in the acute stage but during convalescence, are 
cream, all top-milk mixtures, and also the malted foods. Infants, when 
very ill, are much more likely to take too little than too much food. A 
careful record should be kept of the amount actually taken in each 
twenty-four hours. In no case should food be given oftener than every 
three hours, and usually the intervals should be longer, water and stimu- 
•lants being allowed between the feedings. In older children the diet 
during the acute stage should be much the same as in infants. At a later 
period, rare scraped beef, kumyss, buttermilk, skimmed milk, and zoo- 
lak will be found useful, and during convalescence, eggs, boiled milk, or 
milk gruels made with rice or barley. Special care should be given to 
the diet for a long time. For months after an acute attack the intes- 
tines are very easily deranged. Relapses are excited by changes in the 
temperature, by great fatigue or exhaustion, but most of all by improper 
feeding. Especially in older children should such articles as cream, 
oatmeal, potatoes, corn, tomatoes, green vegetables, and all fruits be 
withheld for a long time. I have seen a single peach, given to a child 
two years old, excite a dangerous relapse, and a few raisins a fatal 
one. 

Medicinal and Mechanical Treatment. — Cases, the early stage of 
which is marked by vomiting and thin diarrhceal stools, are to be man- 
aged at the outset according to the plan outlined in the previous chapter, 
viz., free purgation, irrigation of the colon, and stopping all food. When 
the symptoms of acute inflammation are evident from the outset, as 
shown by the frequent bloody and mucous stools with tenesmus and 
pain, the measures to be depended upon are castor oil or saline cathar- 
tics, irrigation of the colon, and later opium and bismuth by the mouth. 
or oil should be administered in a full dose at the outset — one 
drachm at six months, two drachms at one year, and half an ounce 
at four years. Its primary effect is to clear the intestines, and its sec- 
ondary effect is soothing. The salines may be used as described in the 



ACUTE ILEO-COLITIS.— DYSENTERY. 383 

previous chapter. If the stomach is at all irritable, calomel, one-fourth 
grain every half-hour for five or six doses, may he substituted. Opium 
is usually required on account of the pain, tenesmus, and great frequency 
of stools. The dose should be regulated by the severity of these symp- 
toms. The deodorised tincture and paregoric are, I think, preferable 
to other preparations. Repeated small doses are better than a single large 
close. It is very important that opium should be withheld for at least 
twelve hours after the initial purgative. 

As the pathological process is principally in the colon, and most 
severe in the lower half of the colon, it can often be much more effectively 
treated by injections than by drugs given by the mouth. Irrigation of 
the colon is one of our most valuable means of treatment in these cases. 
For general purposes a saline solution at 100° to 104° F. should be 
employed. One or two quarts should be given at one time; it should 
be injected high into the colon through a rectal tube, and early in the 
disease repeated at least twice a day. When the tenesmus is very great 
and blood abundant, small injections of either hot water (106° to 110° F.) 
or ice water may be used, and later astringent injections. 

The most useful astringent is tannic acid of which one drachm may 
be added to a pint of hot water. Whether injections are to be used 
regularly or not will depend much upon the patient. If they are well 
borne, they may be given once or twice a day during the attack; but if 
at every attempt to give them the child struggles, screams, and resists, 
they may do more harm than good. Complete rest is a very important 
part of the treatment. 

For cases not influenced by the measures mentioned, or those not 
seen at the outset, bismuth should be tried, but it is of no use whatever 
unless large doses are administered. From two to four drachms of the 
subcarbonate should be given in twenty-four hburs to a child two years 
old, and proportionate doses to older children. This may be suspended 
in mucilage. Tenesmus and pain are sometimes relieved by the injection 
of three or four ounces of a starch solution to which from five to ten 
drops of laudanum are added. Severe tenesmus, when not controlled 
thus, and when associated with prolapsus ani, is sometimes immediately 
relieved by a suppository containing cocaine. Xot more than one-fourth 
grain should be used for a child of three years. 

Although a serum has been produced which protects animals against 
inoculation with the B. dys enter ice, its use in the treatment of the various 
forms of ileo-colitis in children has not been followed by any very strik- 
ing benefit. 

Alcoholic stimulants are needed in many cases. They are indicated 
by a weak pulse, cold extremities, and great general prostration, no 
matter at what stage in the disease these symptoms are seen. Brandy 
is usually to be preferred. Generally not more than fifteen or twenty 






DISEASES OF THE DIGESTIVE SYSTEM. 



drops every three hours are needed for an infant one year old. Brandy 
should always be well diluted. 

In cases where Bymptoms have lasted two or three weeks, and the 

active ones have subsided, where the temperature is scarcely above 100° 
V.. and the stools reduced io four or five a day, it is wise to stop 
all medication and attend only to the feeding, with irrigation of the 
colon every two or three days. One is often surprised at this stage to 
find that patients do better without drugs than with them. The prevail- 
ing tendency is to overdose eases of this type. Careful attention to diet, 
judicious stimulation, occasional irrigation of the bowel, with change of 
air. will do much more than any amount of medication. During con- 
valescence general tonics are required, such as arsenic, iron, nux vomica, 
aud wine. 

CHRONIC ILEO-COLITIS. 

The severe forms of chronic ileo-colitis follow acute ileo-colitis, usu- 
ally the catarrhal or follicular form, as the membranous is so severe 
that the patients rarely survive the acute stage. There may be only a 
chronic catarrhal inflammation of the mucous membrane, or ulcers may 
be present. The milder forms are usually the result of chronic intestinal 
indigestion. 

Lesions. — Catarrhal Form. — In its milder form it is fairly common, 
but in its severe form it is exceedingly rare. There may be changes in 
a large part of the small intestine and in the stomach, as well as in the 
lower ileum and colon. 






Fig. 03. — Chronic Catarrhal Inflammation of the Ileum. The lesions affect the 
mucosa, A, almost exclusively. It is somewhat thickened; there is extensive destruc- 
tion of the tubular follicles, remains being seen at T, T; there is a great increase in 
the cells, and some new connective tissue in the mucosa. Large new blood-vessels 
are seen at C, C. History. — Delicate child, thirteen months old ; diarrhceal symptoms 
for four months; during the first two weeks there was high fever; at death weighed 
eight pounds. The gross changes at the autopsy were very slight. The section is 
from the middle ileum. 



The gross appearance of the intestine often differs very little from 
the normal. The mucous membrane is usually of a dull gray or slate 
colour. Pigmentation may occur as striae in the mucous membrane, but 



CHRONIC ILEO-COLITIS. 385 

more frequently it is limited to Peyer's patches and the solitary lymph 
nodules; these, as well as the mesenteric lymph nodes, are generally 
swollen. 

The microscopical changes are usually marked. The lesion is chiefly 
one of the mucosa (Fig. 63). The important features are a disappear- 
ance of very many of the tubular glands, and, in the small intestine, of 
the villi also. There is a very marked cell proliferation in the adenoid 
tissue of the mucosa, and if the disease has existed long enough there 
may be a production of new connective tissue. The solitary lymph 
nodules show usually nothing but cell hyperplasia. The lesions are not 
uniformly distributed, but occur in patches throughout the intestine. 
When present in the stomach, they are of the same kind as those described 
in the intestine, although rarely so severe. In milder cases the gross 
appearances may show very little change to the naked eye, except swell- 
ing of the lymph nodules. Under the microscope there may be found 
more or less extensive cell infiltration of the mucosa, but rarely any 
destructive changes or new connective tissue. 

Ulcerative Form. — This is rather rare, for the reason that in infancy 
a very large proportion of the cases die during the acute stage. 

The ulcers are nearly always of the follicular variety; occasionally 
they are broad and shallow. If the patient dies after an illness of from 
six to eight weeks, the appearances do not differ essentially from those 
described in acute cases. If life is prolonged from two to four months, 
ulcers are found in various stages of repair. Follicular ulcers require 
from one to three months for cicatrisation, and the broad superficial 
ulcers even a longer time. It is very doubtful whether stricture ever 
results from these ulcers in children. The mucous membrane shows 
almost invariably evidences of more or less extensive chronic catarrhal 
inflammation. Among the very rare lesions are cysts of the colon. 
Fully developed cysts I have seen but once. The child had an attack 
of acute ileo-colitis, which became chronic, lasting about five months. 
He never regained his health, and died one year later from intercurrent 
disease. In the descending colon and rectum, about twenty cysts the 
size of a pea, and many smaller ones, were found. They had a thin, 
translucent covering. On section, a thick, transparent, gelatinous ma- 
terial escaped. They were situated in the submucosa, and were un- 
doubtedly produced by the dilatation of some of the tubular glands whose 
orifices had been obliterated. 

Associated Lesions. — The important ones are in the lungs, the most 
common being hypostatic congestion, subacute or chronic broncho-pneu- 
monia, more rarely pulmonary tuberculosis. It is rare to find the lungs 
perfectly healthy. The liver is often found extremely fatty in cases 
associated with great wasting, but in no case have I seen hepatic abscess. 
The kidneys usually show a more or less intense cloudy swelling, and 
26 



DISEASES OF THE DIGESTIVE SYSTEM. 

Bometimee there may be well marked nephritis. Dropsical effusions into 
the Berous ca\ ities are rare. 

Symptoms.- In the milder cases there are only the symptoms of 
chronic intestinal indigestion with the constant presence of mucus in the 
stools, usually in large amount. 

The severe cases are usually seen in autumn, and are generally the 
sequel of acute attacks occurring during the summer. 

The signs of active inflammation have passed away; the temperature 
is usually normal ; there is no pain or tenderness. There is, however, 
no improvement in the general condition, and either the weight remains 
stationary, or the child continues to lose slowly until it is little more 
than a skeleton. The face is pinched, the eyes sunken, and the cheeks 
hollow. The lips are pale, often fissured, and bleed readily. The fon- 
tanel is depressed. The body is so small that the head seems much too 
large. The skin hangs in loose folds on the thighs. The mouth is often 
the seat of thrush, of catarrhal, herpetic, or rarely of ulcerative stomatitis. 
The tongue may be heavily coated, but is more often dry, glazed, and 
red. 

Although they seldom cry for food, as a rule these children will take 
nearly everything given them, and in almost unlimited amount. Not- 
withstanding that it is retained, the more they are fed the more rapid 
seems the wasting. Vomiting is not common, and seldom occurs except 
from overloading the stomach or during acute exacerbations. 

The stools are rarely frequent, five or six a day being the average; 
often there may be only two or three a day for a week at a time. They 
are thinner than normal, but are not often fluid. They usually contain 
mucus of a green or brownish colour, often in large quantity, but rarely 
blood. The stools may consist almost entirely of a green or greenish- 
brown fluid. They are large in proportion to the amount of food taken. 
Undigested food is always present in quantity, and upon the diet de- 
pends very much the gross appearance of the stool, the odour of which 
is almost always offensive. Pus is often found under the microscope,' 
but is rarely visible to the naked eye. A form of stool believed to be 
characteristic of wide-spread inflammation of the mucous membrane 
with atrophy of the tubular glands is one of nearly normal consistence, 
homogeneous, dark brown in colour, and very offensive. 

Prolapsus ani is not so frequent as in the acute cases; but when it 
occurs it is generally more difficult to control. Flatulence and colic are 
prominent symptoms in some cases, but absent altogether in many others. 
As a rule, there is neither abdominal pain nor tenderness. The abdomen 
is usually distended, and in most cases the enlargement is uniform, but 
sometimes there is marked epigastric prominence, which is more often 
from dilatation of the transverse colon than of the stomach. Although 
the mesenteric glands are enlarged, they can not be felt through the 



CHRONIC [LEO-COLITIS. :w7 

abdominal walls. The skin is dry and scaly, and in the worst cases fre- 
quently covered with small petechia over the abdomen and lower ex- 
tremities. About the anus, and over the sacrum, thighs, genitals, and 
sometimes the feet, there are excoriations, and not infrequently ulcera- 
tions. The temperature is elevated only during exacerbations, or from 
inflammatory complications. A subnormal temperature is frequently 
met with. I have occasionally seen it 95° F. in the rectum. The urine 
often contains an excessive amount of indican. Dropsy is often present 
without albuminuria. The weight is stationary, or steadily falls to an 
almost incredible degree. I have seen one infant weighing but eight 
pounds at thirteen months; another, thirteen pounds at two years and 
four months. Ulcers of the cornea are not uncommon. Nervous symp- 
toms are always present. The children are cross and irritable, sleep 
badly, and frequently have a low, whining cry, which is continued much 
of the time. Sometimes they are dull, apathetic, and quite indifferent 
to their surroundings. Persistent opisthotonus is occasionally seen; 
and there may be contractions of the extremities, but rarely general 
convulsions. 

The duration of the disease is from two months to a year. The 
progress is irregular, and marked by periods of improvement, during 
which for a time the patient may hold his own, or even gain in weight. 
Any trivial cause may excite a relapse, and the downward progress is 
rapid. Death often occurs during one of these exacerbations, or it may 
be due to broncho-pneumonia, tuberculosis, or slow asthenia. 

Diagnosis. — It is important to distinguish the cases with marked 
cachexia and slow convalescence, although ultimately resulting in com- 
plete recovery, from those which present at a certain stage almost iden- 
tical symptoms, and yet go on steadily downward, terminating fatally. 
The difference in these cases is really a difference in the character and 
extent of the lesions. The first group are probably cases of superficial 
catarrhal inflammation, or of follicular inflammation which has not gone 
on to ulceration, these lesions being capable of repair. The second group 
are the cases of ulceration, in which complete recovery from the lesions 
is impossible, and repair only partial, if indeed any occurs. In dis- 
tinguishing between these groups the most important guide is the nature 
of the symptoms during the antecedent acute attack. The longer the 
acute symptoms have lasted and the higher the temperature, the greater 
probably is the extent of the lesions, and the more severe their character. 

The diagnosis of chronic ileo-colitis from general tuberculosis is 
often difficult. Except for those whose general condition is extremely 
bad the differential diagnosis can usually be made by the cutaneous 
tuberculin test. Tuberculosis is more likely to be met with in institu- 
tions, among the poor of cities, and in children previously delicate and 
with a tuberculous family history. 



;^ss DISEASES OF THE DIGESTIVIj SYSTEM 

Prognosis. — The prognosis depends upon the child's previous condi- 
tion, upon the duration v( the intestinal symptoms, upon our ability 
to carry out proper treatment, upon the presence of complications ; but, 
of all, upon the severity and extent of the intestinal lesions. The 
possibility o( error always exists in estimating the gravity of the lesions, 
so that no rase should be considered hopeless. The most unpromising 
sometimes end in complete recovery. If, however, continuous 
symptoms have existed for eight or ten weeks without any sign of im- 
provement, recovery is extremely doubtful. The patient may linger for 
two or three months longer, but usually only to be carried off by the 
first acute disturbance which occurs. 

Treatment. — No greater mistake is made than to give these children 
week after week the various diarrhoea-mixtures, with the expectation 
that ultimately the formula which exactly meets the particular case will 
be found. Drugs are to be used only for the relief of special symptoms. 
Thus a dose of opium may be needed when the movements are unusually 
frequent, or castor oil, or calomel occasionally when the stools are 
particularly offensive. The essential and important part of the treat- 
ment consists in injections, careful feeding, and change of air. Astrin- 
gent enemata, however, are of some value. They should not be given 
continuously, but from time to time should be omitted for a week or two 
to see what the condition of the stools is without them. I have seen 
several cases of the milder variety where the constant use of such injec- 
tions seemed to be an important factor in keeping up the production of 
mucus. The colon should first be washed with a large amount of a tepid 
salt solution, and then four or five ounces of the astringent solution 
injected, and held in place by compressing the buttocks for half an hour. 

Alcohol is often useful but it should be given in moderate amounts 
and well diluted. Port or sherry is often better than brandy or whiskey. 
The diet advised for later stages of the acute cases should be continued. 
Fat and starchy foods should be excluded for a long time and then given 
in small quantities and cautiously. The fat of cow's milk especially 
should be avoided; olive oil, however, can usually be given at an earlier 
period and in many cases is borne surprisingly well. Kumyss and zoo- 
lak, skimmed milk, and buttermilk are useful. To these articles may 
be added, beef juice, rare scraped beef, and the whites of fresh eggs, 
partially cooked. The diet should be directed according to its effect 
upon the stools. Much information may be obtained by thoroughly wash- 
ing the stools and examining the residue. Nutrition may be promoted 
ine degree by inunctions of cocoa butter, cod-liver oil, or some 
other form of fat. 

The patients should be placed in the best possible surroundings; in 
no dif a change of air more to be desired than in this. They 

should be in the open air as much as possible but should be kept warm, 



AMYLOID DEFENERATION OF THE INTESTINES. 389 

for their temperatures quickly fall to subnormal. The danger of relapses 
and acute exacerbations continues long alter the primary attack has sub- 
sided. 

AMCEBIC COLITIS. 

Amoebic colitis is rare in children; it is particularly so in infants, 
probably owing to the fact that nearly all the water taken at this age 
is boiled. Most of the cases in children thus far reported have been 
observed in warm climates, although Amberg has recorded five which 
occurred in Baltimore, the youngest child being two years and eight 
months old. 

The symptoms in the few cases that have been reported in children 
have differed in no important particular from the disease as seen in 
adults. In exceptional cases the onset may be abrupt and the attack 
may run an acute course, terminating fatally in two to three weeks. 
Such cases are characterised by much abdominal pain and tenderness, 
frequent mucous and bloody stools containing amoebae, and some fever, 
which, however, seldom reaches 102° F. 

More frequently this acute onset is followed by a subacute or chronic 
form of the disease, or the disease may be subacute from the beginning. 
The protracted cases are the type of the disease most frequently seen. 
They are very obstinate to treatment. Periods of constipation and 
apparent recovery often alternate with exacerbations in which the bloody 
and mucous stools return, with pain, tenesmus, and slight fever. The 
duration may be from a few months to one or two years. Death may 
finally occur from exhaustion with extreme wasting, or from some com- 
plication, such as haemorrhage, abscesses of the liver being very rare in 
children. The diagnosis from other forms of colitis is made only by the 
discovery of amoebae in a freshly voided stool. 

The general treatment is the same as for other forms of acute or 
subacute colitis. The special treatment for the purpose of destroying 
the amoebae is the use of injections of quinine which may be employed 
in solutions varying in strength from 1 to 5,000 to 1 to 250. 



AMYLOID DEGENERATION OF THE INTESTINES. 

This is rarely met with in infants. It is not so infrequent in older 
children, where it is associated with amyloid changes in the liver, spleen, 
and kidneys, usually as a result of prolonged suppuration in connection 
with bone tuberculosis. It is sometimes met with in syphilis. The ileum 
is the part of the intestine most affected. The process begins in the 
walls of the arterioles and capillaries, particularly of the villi, and later 
involves the vessels of the submucosa; subsequently the epithelium may 
be affected. The mucous membrane in these cases is pale, somewhat 



390 DISEASES OF THE DIGESTIVE SYSTEM. 

translucent The condition is recognised by the application of the iodine 

the affected villi become of a brownish-red or mahogany colour. 

Amyloid degeneration produces do definite symptoms. Diarrhoea is 

frequent luit by do means constant. The anaemia and waxy cachexia 
which are present are probably dependent much more upon the associated 
lesions of the liver and kidneys than upon the changes in the intestines. 



TUBERCULOSIS OF THE INTESTINES AND MESENTERIC LYMPH 
NODES MESENTERIC GLANDS). 

These two conditions are usually, but not invariably, associated, and 
may be conveniently considered together. 

Frequency. — In a series of 386 autopsies upon tuberculous cases 
from my own hospital records, the intestines were involved in 40 per 
cent. The great majority of the patients were under three years of age. 
In 131 autopsies upon tuberculous cases published in the Pendlebury 
Hospital Reports, the intestines were involved in 50 per cent. These 
patients were mainly between four and fourteen years old. In 209 autop- 
sies upon tuberculous children, chiefly infants, reported by Muller, the 
intestines were involved in 28 per cent. In 1,346 autopsies collected by 
Biedert there were intestinal lesions in 31.6 per cent. These figures 
show that tuberculosis of the intestines is not one of the most frequent 
forms in children, and that it is rather less frequent in infancy than at 
a later age. It is most common from the third to the eighth year. The 
mesenteric lymph nodes were tuberculous in 44 per cent of my own 
autopsies, and in 59 per cent of the Pendlebury cases; occurring thus 
in both series with slightly greater frequency than tuberculosis of the 
intestines. 

Etiology. — In the great majority of cases the mesenteric lymph nodes 
are infected from the intestines. It is possible, but I believe exceptional, 
for the infection to occur through the general circulation. With tuber- 
culous ulcers of the intestine, the lymph nodes are invariably found by 
inoculation in animals to be tuberculous; although they may not yet be 
caseous. The infection of the intestinal mucous membrane is from 
bacilli in the canal. Much stress has been laid upon tuberculous milk 
as a means by which children are infected. Primary tuberculosis of the 
Mies is in this country relatively a rare condition. I have records 
of less than a dozen such cases in nearly four hundred autopsies upon 
tuberculous patients. When it does occur, however, primary tubercu- 
of the intestine has been in my cases more often due to a bacillus 
of the bovine than of the human type; the inference, therefore, is prob- 
ably justified that tuberculous milk was the source of the infection. The 
intestinal lesions most frequently found are, however, mild in character 
and usually associated with and probably secondary to an advanced pul- 



TUBERCULOSIS OF THE [NTESTINES. 39J 

monary process. They are doubtless due to swallowing tuberculous 
sputum. In such cases the human type" of bacillus is round. 

Lesions. — Intestines. — The usual seat is the small intestine, chiefly 
the jejunum and lower ileum. With extensive disease the large intes- 
tine may also be involved, most frequently the caecum, and exceptionally 
it alone may be affected. Tuberculous ulcers may be found in the 
appendix. 

The early deposits appear as tiny yellow nodules, generally widely 
scattered and affecting Peyer's patches. Usually, however, ulcers are 
present, and often only ulcers are seen. Their size and number vary 
greatly; there may be only five or six tiny ulcers, or there may be forty 
or fifty, the largest being two or three inches in diameter. They very 
frequently involve Peyer's patches. The typical tuberculous ulcer is of 
irregular shape, with rounded borders and with its longest diameter at 
right angles to the intestinal axis. When large, it may nearly encircle 
the gut. The ulcers are excavated; they have overhanging, infiltrated 
edges of a deep-red colour. The surface is covered with granulations. 
In those which have partially healed a distinct puckering of the intestine 
occurs, which is especially noticeable upon the peritoneal surface. The 
small ulcers involve the mucosa only; the larger and older ones the 
submucosa and the muscular coats, and not infrequently also the serous 
coat. Perforation may occur, but rarely into the general peritoneal cav- 
ity, as a localised plastic inflammation precedes it. There may be ad- 
hesions of adjacent intestinal coils, and fistulae may form, owing to ulcer- 
ation at the point of contact. With these severe cases there is always 
associated more or less extensive tuberculous peritonitis, frequently of 
the ulcerative variety. Like other tuberculous processes, the infiltration 
and ulceration may cease at any stage, and cicatrisation follow. If the 
ulcers have been large ones, there is always some narrowing of the lumen 
of the intestine. Stricture is rarely seen because most patients die from 
the genera] disease before it has had time to occur. Monti has reported 
a case of obstruction at the ileo-caecal valve, due to an old tuberculous 
cicatrix, in an infant of twenty-one months. One has come under my 
observation in a child of nine years, in which the obstruction was in the 
colon, just beyond the ileo-caecal valve. 

Mesenteric Lymph Nodes. — Usually these tuberculous lymph nodes 
are from half an inch to an inch in diameter; occasionally they may 
reach the size of a hen's egg. From a fusion of several of them, tumours 
of considerable size may be formed. I have seen one such mass as large 
as the head of a child at birth. 

The process is the same as that which occurs in other lymph nodes 
of the body. There is a tuberculous inflammation, followed by caseation, 
softening and abscess, or by calcification. Localised peritonitis is found 
in all the marked cases; this is usually plastic, but may be suppurative 



392 DISEASES OF THE DIGESTIVE SYSTEM. 

when duo to the rupture o\' an abscess. Pressure upon the vena cava 
may lead to dropsy in the lower extremities. Ollivier has reported a case 
in which thrombosis of the vena cava occurred. Pressure upon the portal 
vein may load to ascites and dilatation of the superficial abdominal veins. 
There may be pressure upon the thoracic duct. 

Symptoms. — The symptoms of intestinal tuberculosis are exceedingly 
irregular. Ulcers are very frequently found at autopsy when there have 
been uo marked intestinal symptoms; this is especially true of the small 
ulcers usually seen in infants. On the other hand, diarrhoea is not 
uncommon in eases of advanced general tuberculosis where no ulcers are 
present. It is the most frequent symptom, and may be exceedingly ob- 
stinate. The stools do not differ essentially from those in chronic ileo- 
colitis, exeept in the occurrence of haemorrhages and in the presence of 
tubercle bacilli. Haemorrhages are not very frequent, but they may be 
so large as to be the cause of death. This occurred in one of my cases, 
an infant nine months old, the blood coming from a single ulcer in the 
ileum. Haemorrhage is more common in older children. In some cases 
localised abdominal pain or tenderness is present. In advanced cases 
the symptoms of intestinal ulceration are usually mingled with those of 
peritonitis, and there are also present the enlarged mesenteric lymph 
nodes, which may aid in the diagnosis. In the vast majority of cases, 
these nodes are recognised only by deep palpation. The tumours are 
generally felt as irregular nodular masses, lying close against the 
spine, not movable, and sometimes tender on pressure. Other tu- 
mours from deposits in the peritonaeum may be present anywhere in 
the abdomen; they may be superficial or deep. The other symptoms 
are due to the complications already mentioned and to tuberculosis 
elsewhere. 

Diagnosis. — The only positive evidence of intestinal tuberculosis is 
the discovery of the bacilli in the stools. They are here to be carefully 
differentiated from smegma and other forms of acid-fast bacilli. In the 
absence of such evidence, the disease is differentiated from simple ileo- 
colitis, first, by the signs of tuberculosis elsewhere in the body, espe- 
cially in the lungs, these being almost invariably involved; secondly, by 
the slow onset and gradual development of the symptoms, while in 
chronic ileo-colitis an acute attack has almost invariably preceded. 
Large haemorrhages always suggest tuberculosis. A positive reaction 
to the tuberculin test is of much assistance in diagnosis. 

The large mesenteric glands are recognised only as abdominal tu- 
mours. 

Prognosis. — This depends altogether upon the extent of the tubercu- 
lous disease elsewhere, as it is extremely rare for the intestinal lesion to 
be the cause of death. Once formed, the ulcers probably remain, cica- 
trisation being very rare, and then only partial. 



CHRONIC INTESTINAL INDIGESTION. 393 

Treatment. — The only symptom which ordinarily demands treatment 
is the diarrhoea. When severe, this is to be managed much as in cases 
of ileo-colitis, except that irrigation of the colon is, of course, not called 
for. The chief reliance must be upon diet and internal medication. The 
drugs which are most useful are bismuth, opium, and creosote; the last 
mentioned should be given in pills coated with shellac. 



CHAPTER VIII. 

DISEASES OF THE INTESTINES.— (Continued.) 

CHRONIC INTESTINAL INDIGESTION. 

As the larger and more complex part of the process of digestion goes 
on in the intestine, intestinal indigestion is a more common and more 
complicated disturbance than is gastric indigestion. In many cases we 
find the two associated, but in perhaps the majority the symptoms relate 
entirely to the intestinal process. The conditions seen in young infants 
are so different from those in older children that the cases may be best 
considered separately. 

In Young Infants. 

The general causes are the same as those mentioned in connec- 
tion with chronic gastric indigestion : constitutional debility, either con- 
genital or acquired, unfavourable surroundings, and previous attacks 
of acute disease. Chronic intestinal indigestion is especially common 
during the first six months, and is seen both in nursing infants and in 
those who are artificially fed. In the case of breast-fed infants, the 
mother is often highly nervous, delicate, and anaemic, and may be taking 
large quantities of fluids of every description, for the purpose of main- 
taining an abundant flow of milk. Why it is that the milk causes so 
much disturbance can not always be discovered even by the most careful 
analysis. Sometimes the trouble is simply that the milk is too rich, 
chiefly in fat. Disturbances may come, although rarely, from over- 
feeding. 

In infants who are being fed upon cow's milk, the most common 
cause is that the fat is excessive; sometimes it is the sugar, and it may 
be both. When once begun a striking intolerance of both fat and sugar 
persists for a long time. Another very important cause is the use of 
farinaceous foods too early, in too large quantities, and often insuf- 
ficiently cooked. 

Lesions. — Strictly speaking, chronic indigestion is a functional dis- 
order without anatomical changes. When the condition has lasted for 



;\\)\ DISEASES OF THE DIGESTIVE SYSTEM. 

many works or months, as often happens, there may result a low grade of 
catarrhal inflammation in the colon, frequently attended by hyperplasia 
of the lymph nodules of the mucous membrane, and sometimes by a 
similar process in the mesenteric lymph nodes. Chronic indigestion 
may be the principal and the only symptom in cases of chronic ileo- 
colitis which follow acute attacks. 

Symptoms. — The general symptoms are those of malnutrition, or in 
the more severe form, those of marasmus. These have already been fully 
described, and need only be mentioned here. The most important are, 
stationary or falling weight, anaemia, poor circulation, often subnormal 
temperature, almost constant fretfulness and crying, with very little 
quiet sleep. The tongue may be coated or quite clean. The appetite is 
often good, these infants taking food whenever given, and in an almost 
unlimited quantity. There are few cases in which occasional vomiting 
does not occur, but it is rarely persistent. 

So far as the intestinal condition is concerned, the cases may be 
divided into those with diarrhoea and those with constipation. It may 
happen that the same child will suffer for a long time from diarrhoea 
and then from constipation, or the reverse; but usually one condition 
or the other is habitual. The diarrhceal stools are thin, green, and 
contain undigested food and mucus. They vary in number from three 
to six or eight in twenty-four hours. They are commonly passed with- 
out pain, although there may be flatulence. The stools have usually a 
sour, unpleasant odour, but they are rarely foul. They may be irritat- 
ing to the skin, and cause troublesome excoriations or intertrigo. In 
some cases the stools contain but little solid matter, the character being 
that of yellowish-green water. In most of the cases, after the process 
has lasted two or three weeks, mucus is present, and may then become a 
constant feature. 

If there is constipation, the stools are usually gray or white; they 
are smooth and pasty or like hard balls and passed after much straining, 
often coated with mucus and sometimes streaked with blood. These 
stools contain an excessive amount of fat, especially in the form of 
soaps and also a larger proportion of inorganic matter than is normal, 
particularly calcium salts. Often the bowels will not move for days 
except after the use of laxatives or enemata. The latter frequently have 
but little effect, as the rectum may be empty. Constipated cases are 
especially prone to suffer much from flatulence and colic, the attacks of 
which may he very severe. 

The duration of these symptoms is indefinite. There is little or no 
tendency to spontaneous improvement, and they may drag on for several 
months or until the problem of diet is solved. The progress of these 
is marked by frequent exacerbations, during which there is vomit- 
ing, and usually fever. Such symptoms are generally dependent upon 



CHRONIC INTESTINAL INDIGESTION. 395 

intestinal toxaemia. A low irregular fever may continue for days or even 
weeks. Although the general symptoms of failing nutrition are present 
in most eases, a mild degree of chronic intestinal indigestion with fre- 
quent loose movements may sometimes last for months, during which 
the patients may gain steadily in weight and give every indication of 
being well nourished. This is much more common in nursing infants 
than in those who are artificially fed. 

Diagnosis. — It is not generally difficult to determine that an infant is 
suffering from chronic intestinal indigestion; but one should endeavour 
to go further in his diagnosis and discover which of the elements of the 
food is causing the chief disturbance. Much valuable information may 
be gained from a careful history of what has already been tried in the 
case; often some gross error can be detected in the proportions of the 
food elements, the quantity of food given or its preparation. Difficulty 
with the fat is sometimes indicated by loose movements, usually of a 
yellow or yellowish-green colour. Sometimes they are clay coloured, 
smooth and formed, with a peculiarly offensive odour ; there may be 
vomiting or the regurgitation of food in small quantities. Difficulty 
with the sugar is often associated with flatulence, colic, and diarrhoea, 
with thin, sour, irritating stools. Difficulty with the starch leads to 
much flatulence and colic, diarrhoea alternating with constipation, and 
offensive stools. One may find the foregoing symptoms in any combina- 
tion, for although in the beginning the trouble may be with but a single 
element of the food, this is rarely true when the child comes under 
observation. By carefully noting the symptoms which follow the use 
for a few days of a simple milk formula, such as fat 1 per cent, sugar 
5 per cent, protein 0.9 per cent (one-fourth whole milk), one can often 
arrive at a conclusion as to which element of the food is producing 
the most disturbance. 

Prognosis. — This depends almost entirely upon how early the cases 
come under treatment and how they are managed. There is very little 
tendency to spontaneous improvement or recover} 7 . The outlook is much 
better in cases with constipation than in those with diarrhoea. In the 
latter, progress is very difficult as the intolerance of food is so great 
that increase in weight is well-nigh impossible. The existence of chronic 
intestinal indigestion is one of the most important predisposing causes 
of more serious forms of intestinal disease. 

Treatment. — Drugs have no part in the treatment of these cases, ex- 
cept now and then for particular symptoms, such as diarrhoea, constipa- 
tion, or colic. These infants are cured by proper dietetic and hygienic 
measures, and by these alone. The diet has already been discussed in the 
chapter on Infant-Feeding, and the general management, not less im- 
portant, in the chapter on Malnutrition. 






DISEASES or THE DIGESTIVE SYSTEM. 



/// Outer Children. 



Chronic intestinal indigestion is especially common in children from 
the lirst to the fifth year. With the younger children, solid food has 
generally been given too early and in too large quantities. The articles 
from which most trouble is seen arc imperfectly cooked cereals, vegetables 
of all kinds, hut especially potato. Often the diet is composed almost 
entirely of farinaceous foods and bread. The condition often follows 
an attack of acute diarrhoea or dysentery. Children suffering from 
rickets are particularly liable to be affected. The disease is seen in 
all grades of society. 

Symptoms. — The clinical picture which these cases present is a very 
common one, and the symptoms are quite uniform. The patients are 
generally very thin, with very small extremities, a small amount of fat, 

and a large protuberant abdomen (Fig. 
64). There is much flatulence, and usu- 
ally there is marked tympanites. Such 
children are pale, anaemic, and sallow in 
complexion ; they have dark rings under 
the eyes; they are fatigued on slight ex- 
ertion; they are very cross, irritable, and 
emotional to an unnatural degree. They 
are hard to amuse, hard to control, and 
altogether exceedingly difficult patients to 
deal with. Their growth is retarded if the 
symptoms have lasted long. They are 
much below the average in height and 
weight, but mentally often quite preco- 
cious. One of my patients at five years 
weighed twenty-two pounds and was thirty- 
three inches tall. The sleep is always un- 
natural and disturbed; and at night they 
toss about their cribs, waking frequently, 
crying out and often grinding their teeth, 
lliis sometimes leading to the diagnosis of 
intestinal worms. They perspire very read- 
ily, and suffer from cold extremities. 

The bowels are usually constipated, the 
stools being of a light gray colour or nearly 
white. The odour from the discharges is 
usually extremely foul. This condition may alternate with diarrhoea. The 
-tool- are then not very frequent, rarely exceeding four or five a day, but 
they are large, gray, green, or brown in colour, often frothy, offensive, and 
always contain undigested food. They are in many cases excited by the 




Fig. 64. — Chronic Intestinal 
Indigestion. — Patient four 
years old; symptoms of three 
3 r ears' duration, following at- 
tack of acute ileo - colitis. 
Height, 34 inches; circumfer- 
ence of abdomen, 22? inches; 
weight, 24 pounds. 



CHRONIC INTESTINAL INDIGESTION. 397 

inking of food. From time to time, in many patients, large quantities of 
mucus are passed; in some cases this comes to be a constant feature of 
the disease. Large quantities of gas are expelled. Pain is not a very 
common symptom in most cases. The appetite is capricious and usually 
poor, though some patients will eat everything offered. The tongue may 
be coated; but unless the stomach is also affected it is usually clean and 
the breath is not offensive. 

The nervous symptoms which these patients present are exceedingly 
varied, and often of the most puzzling character. In many cases they 
are so severe and so persistent as to lead to the diagnosis of organic 
disease of the brain. In addition to the condition of general nervous 
irritability, there may be tetany, fainting attacks resembling somewhat 
the seizures of petit mal, exaggerated reflexes, attacks of dulness or some- 
times stupor, with retracted abdomen, irregular pulse and respiration, 
and other symptoms strongly suggestive of tuberculous meningitis. Con- 
vulsions are not uncommon. They are usually accompanied by fever, 
and may be repeated at intervals of a few minutes. There is almost no 
end to the combinations of nervous symptoms which these patients may 
present. Most of them are toxic in their origin. The skin shows fre- 
quently eruptions of erythema or of urticaria. 

Slight fever is sometimes present for weeks, the temperature usually 
varying between 99° and 101.5° F. Sometimes for several days it may 
be normal, and occasionally may rise to 102° or 103° F. during a slight 
exacerbation in the symptoms. The urine of most of these patients con- 
tains a great excess of indican; the amount present indicates very ac- 
curately the degree of intestinal putrefaction, and often fluctuates reg- 
ularly with the nervous symptoms. 

Intercurrent attacks of acute indigestion, with diarrhoea and vomit- 
ing, are common and quite easily excited. The course and duration of 
these symptoms are indefinite. In the most severe forms, if untreated, 
the patients gradually waste until they die from exhaustion, or fall easy 
victims to any acute disease which they may happen to contract. There 
is but little tendency to spontaneous recovery. 

Herter has called special attention to a type of this disease associated 
with marked arrest in growth to which he gave the name Intestinal 
Infantilism. In several such cases studied he found a failure of reten- 
tion of calcium and magnesium salts over a prolonged period of time. 
To this he ascribed the arrested development of the skeleton. Associated 
with this, there were present in all cases evidences of excessive intestinal 
putrefaction. The bacteriology of the condition he believed to be char- 
acteristic, viz., a preponderance of the b. biftdus, with great diminution 
or entire absence of the b. coli. 

Prognosis. — This depends upon the duration of the symptoms, the 
general condition of the patient at the time treatment is begun, and upon 



398 DISEASES OF THE DIGESTIVE SYSTEM. 

how thoroughly it van be carried out. The symptoms, in the great 
majority o( cases, bave existed for several months at the time the case 
comes under observation. Generally, the greater the mistakes in feed- 
ing have been, ami the greater the violation of hygienic and dietetic 
rules, the heller the prognosis. A child who has developed chronic 
intestinal indigestion of a severe type, in spite of the fact that the 
hygienic surroundings were good, ami when the dietetic errors were not 
flagrant, is not nearly so hopeful a subject for treatment as one whose 
hygienic surroundings have been poor and whose diet has been especially 
had. In cases like the latter, a removal of the causes and the institution 
o( proper methods of treatment almost invariably result in immediate 
and striking improvement, unless the general vitality of the patient has 
been reduced to a very low point. In the other cases, where the mistakes 
have been less marked, and the condition is due more to constitutional 
than to local causes, the improvement is slower and less striking. Thus, 
as a rule, hospital patients improve more rapidly than those seen in 
private practice. 

Treatment. — In no class of cases that the physician is called upon to 
treat are results more satisfactory than in many of those of chronic intes- 
tinal indigestion, when intelligent co-operation can be secured. If the 
parents themselves are lax in discipline, and are unable to control the 
child, an efficient trained nurse should be secured, into whose hands the 
exclusive management of the child should be placed. The essential part 
of the treatment is diet and general management. In the second and 
third years the most important thing is to stop all starchy food for a 
considerable time, and put the patient upon an exclusive diet of rare 
beef or beef juice and skimmed milk or buttermilk. After some im- 
provement has occurred carbohydrates may be added, some of these in 
the form of maltose, but chiefly as a well-cooked starchy food. The 
number of feedings should not be more than four a day during the 
second year, and three or four a day for children during the third and 
fourth years. These should always be at regular intervals, and nothing 
whatever given between meals. The meat should be rare scraped beef- 
steak or mutton chop ; from one to three tablespoonfuls may be allowed 
once a day. The white of egg may be given early, and after a time, the 
whole egg. Kumyss and zoolak and buttermilk are often of very great 
value. Although at first they are taken with difficulty, in many cases a 
fondness for them is very soon acquired. 

After improvement has been going on for two months, bread may be 
added, at first in small quantities and once a day. This should prefer- 
ably be stale, cut thin and dried in the oven until it is crisp, and given 
without butter. Two or three times a week raw oysters may be tried. 
Mutton, chicken, or beef broth, without vegetables, may be given occa- 
sionally in the place of one of the milk feedings. After this diet has 



CHRONIC INTESTINAL INDIGESTION. 399 

been kept up for three or four months, if improvement continues, one 
of the green vegetables thoroughly cooked and strained may be added 
once a day. A striking feature of these cases is their marked intolerance 
of the fat of cow's milk. This must be withheld for a long period. The 
form of fat which these patients can take best is usually olive oil, winch 
furnishes a valuable means of increasing weight. Beginning with one 
teaspoonful three times a day the quantity may be increased to two or 
three times this amount. This restricted diet should be continued for 
at least a year or until all the symptoms have disappeared. Potato and 
catmeal should be forbidden for a long time. 

Intestinal irrigation is useful for brief periods in some cases in which 
there is much mucus passed. But it should not be forgotten that con- 
tinued irrigation often keeps up the production of mucus. Astringents 
should not be used, but only a warm saline solution. 

The constipation can sometimes be controlled by the diet alone; but 
in most cases drugs are needed also. Calomel frequently seems to exert 
a very beneficial influence, even when the constipation is not severe. It 
is often wise to administer a full dose every week or ten days. In some 
patients castor oil acts more satisfactorily. It may be objectionable, how- 
ever, from its tendency to aggravate the constipation. As laxatives in 
this condition I have found the greatest satisfaction from the use of 
preparations of cascara and the compound licorice powder. Abdominal 
massage is also useful. 

Drugs directed against the process of putrefaction are extremely un- 
satisfactory even in older children, but sometimes diminution in the 
amount of flatulence follows the use of subgallate of bismuth, carbonate 
of creosote, salol, or salicylate of soda. General tonics are required, 
and may add materially to the improvement of the patients. Altogether 
the best is mux vomica. It may be given in combination with the bitter 
wine of iron just before meals three times a day. Cod-liver oil, partic- 
ularly in the early stage, is badly borne. 

Eelapses are easily excited by indiscretion in diet, and parents should 
be impressed at the very beginning with the necessity of adhering rigidly 
to the diet prescribed, for a long period. It very often happens that the 
improvement which is seen after one or two months of careful treatment 
is so marked as to lead the parents to the belief that a cure has been 
accomplished, so that they relax their vigilance and allow improper 
articles of food which are almost certain to induce a relapse. If the case 
is an aggravated one, and the symptoms of long standing, it is wise to 
tell parents at the outset that a year's treatment is the minimum in 
which anything permanent can be accomplished. 

The general treatment of the patient must not be overlooked. Proper 
clothing, regular exercise in the open air, cool sleeping rooms, massage, 
and sponging every morning with cold water, are all of very great im- 



400 DISEASES OF THE DIGESTIVE SYSTEM. 

portance, and contribute almost as much to the results obtained as the 
special measures adopted. (See chapter on Malnutrition.) 

An elastic abdominal bandage giving moderate support not only 
adds to the com tort of these patients but to some degree prevents the 
excessive distention likely to occur on account of the loss of muscular 
tone in the abdominal walls. 

The improvement in the nervous symptoms of the patient is one of 
the first things noticed, and is often marked in a few days after the 
beginning of treatment. From an irritable, fretful, peevish child the 
patient is sometimes totally changed in disposition in a few weeks, so 
as to become quiet, affectionate, docile, and playful. 

INTESTINAL COLIC. 

The term colic is applied to any severe paroxysmal pain occurring in 
the intestines. It may be due to many causes. The colic of lead and 
arsenic poisoning are both very rare in children; but colickly pains are 
present in appendicitis, intussusception, ileo-colitis, and, in fact, in all 
the severe forms of intestinal inflammation. Colic may be due to swal- 
lowing certain substances, especially foreign bodies and the seeds of 
fruits; and in rare cases it may be excited by the presence of round- 
worms when they are numerous. In all the conditions mentioned, colic 
is only one of the symptoms, although it may be a very prominent 
one. 

The peculiar colic of infancy is clearly caused by spasm of the mus- 
cular wall of the intestine. It is a heightened reflex from irritation of 
which we have many other illustrations at this period of life. The 
cause of the irritation is usually the presence of some undigested food 
in the intestine. Colic is therefore essentially a symptom of indigestion. 
Flatulence and colic are very often, but not always, associated. Colic 
is always increased by the coexistence of constipation, which in many 
cases is its sole cause. Almost any of the elements of the food may give 
rise to colic. 

Sugars and starches may produce it by causing excessive fermenta- 
tion and flatulence. Fats are less frequently at fault; but the presence 
of large unabsorbed masses in the intestine may be a sufficient cause of 
irritation. The actual pain in colic is partly from distention, but chiefly 
from muscular spasm. In some of the most severe cases of colic it is 
possible that the spasm may be accompanied by a slight transient in- 
tussusception. Colic may follow chilling the surface of the body. In 
these cases, also, muscular spasm appears to be the principal factor in 
causing the pain. The colicky period of infancy is chiefly the first 
three months; after this time the peculiar susceptibility gradually 
passes off. 



CHRONIC CONSTIPATION. 401 

Symptoms. — These are in most cases so typical as to be easily recog- 
nised. They are always more severe in delicate and highly nervous chil- 
dren. In the severe attacks there is contraction of the features, a loud 
paroxysmal cry, subsiding for a few moments and then beginning with 
renewed intensity, drawing up of the lower extremities, and in male in- 
fants contraction of the scrotum. With these symptoms the abdomen is 
usually found tense and hard. With the expulsion of the gas, the symp- 
toms subside at once, and the child usually falls asleep. In the most 
severe attacks there may be considerable prostration, cold extremities, 
and perspiration. When the symptoms are less severe there is only con- 
tinual fretfulness, and the child can not sleep. When colic is habitual 
there are very few hours in the twenty-four when the child seems to be 
entirely comfortable. In nursing infants there may at times be difficulty 
in distinguishing the cry of colic from that of hunger, as infants suffer- 
ing from colic will usually take food eagerly, and this is often followed 
by temporary relief. In colic, however, the pain soon returns, and often 
is more severe than before. The cry of colic is usually violent and 
paroxysmal; that of hunger is apt to be prolonged and continuous, and 
is not accompanied by the other symptoms mentioned as indicating ab- 
dominal pain. In older children the less frequent causes of colic men- 
tioned at the beginning of this article, especially appendicitis, should be 
borne in mind. 

Treatment. — When colic is due to flatulence of the intestine, nothing 
given by the mouth has much effect in relieving the symptoms. Cer- 
tainly food should not be given. The purpose of treatment during the 
attack is to assist the child to get rid of the gas; as this is usually in 
the colon, the most efficient means is by massage or enemata. At first 
an injection of four or five ounces of lukewarm water should be used. 
If this is not successful, two ounces of cold water with half a teaspoonful 
of glycerin may be tried. This rarely fails to start peristalsis and expel 
the gas. In conjunction with these measures, dry heat should be applied 
to the abdomen by means of hot flannels or a hot-water bag, and the 
feet should be well warmed. In cases of colic not associated with flatu- 
lence, when the pain is probably the result of muscular spasm, opium 
in some form is required in addition to heat or counter-irritation. The 
treatment between the attacks and the treatment of habitual colic should 
be directed toward the constipation and the indigestion, upon which they 
depend. 

CHRONIC CONSTIPATION. 

Constipation may be said to exist whenever the stools are less fre- 
quent, harder, and drier than normal. During the first six months in- 
f ants usually have two movements a day. Many, however, have only one ; 
but if this is normal in character the child is not constipated. In other 
27 



402 DISEASES OF THE DIGESTIVE SYSTEM. 

cases, although there are two and even three stools a day, they may all 
be small, dry, and hard, having all the characters of constipated stools, 
and the case should be treated accordingly. 

Etiology. — The causes of chronic constipation are many and far- 
reaching. It may be due to a diminution in the secretion of the intes- 
tinal glands or of the liver. The movements are then hard, dry, very 
light-coloured, and are associated with much flatulence and other signs 
of intestinal indigestion. Very often the principal factor in constipation 
is insufficient muscular contraction in the intestine. The faecal masses 
are then propelled so slowly and remain so long in the intestine that 
the fluid portion is absorbed, the residue becoming, in consequence, so 
dry and hard that it is difficult to expel. In other cases constipation 
is due to the fact that there is insufficient volume to the stools, as may 
be the case when the food leaves very little residue. Constipation may 
depend also upon local causes, as, for example, where an evacuation of 
the bowels is resisted on account of pain from fissure of the anus or from 
haemorrhoids. Although not the primary cause, this condition may be 
sufficient to keep up the constipation indefinitely. It may, in rare cases, 
be due to a congenital condition, such as narrowing or twisting of the 
large intestine at some point. Another rare cause seen especially in 
infancy is tonic spasm of the anal sphincter. The most important causes 
of constipation may be grouped under two heads : diet, and conditions 
giving rise to muscular atony. 

Diet. — In breast-fed infants the trouble is usually a lack of fat and 
low total solids in the milk. In those who are artificially fed it is 
often because the fat is too low, and sometimes because both the fat and 
the protein are too low, the stool lacking volume. In other cases the 
cause of constipation is indigestion, in still others the use of sterilised 
milk. During the second and third years the cause may be too much 
cow's milk, particularly that which has been boiled, or the use of an 
excessive amount of starchy food. In older children the cause may 
be an excess of starchy food and a lack of sufficient green vegetables, 
meat, and fruit. 

Muscular Atony. — The most common cause of muscular atony is 
habit ; in a large number of cases lack of proper training is the principal 
etiological factor. If the inclination to have a stool is regularly disre- 
garded it soon ceases to be felt. The ordinary irritation from faecal 
masses produces no response whatever. The longer such a condition 
continues the more obstinate does it become. This is an important 
factor in all cases. Another potent cause of muscular atony is rickets. 
In this disease the muscular walls of the intestine suffer like the muscles 
of the extremities, and become incapable of doing their work. Again, 
any form of malnutrition in which there is feeble muscular tone may 
cause or aggravate constipation. It is often seen as a sequel to acute 



CHRONIC CONSTIPATION. 403 

attacks of diarrhceal diseases, particularly when these have been pro- 
longed. Want of sufficient muscular exercise is a frequent cause. There 
are many children who rarely suffer from constipation in summer when 
they have plenty of out-of-door exercise, who very often do so in winter 
when such exercise is wanting. A loss of muscular tone is not an infre- 
quent result of the prolonged and indiscriminate use of purgative drugs 
or enemata. 

Symptoms. — In many cases no symptoms are present except the local 
ones, the general health being excellent and the nutrition in no way 
disturbed. In the majority, however, there are symptoms of greater or 
less severity, depending somewhat upon the cause of the constipation. 
There may be simply flatulence and colicky pains, or the irritation of 
the hardened faecal masses may produce a slight catarrhal inflammation 
of the sigmoid flexure and the rectum, so that mucus and sometimes 
traces of blood may be passed with the stool. Haemorrhoids may develop 
even in infancy, and frequently the constant straining leads to the pro- 
duction of hernia. In many cases there are from time to time nervous 
symptoms resulting apparently from the absorption of various toxic ma- 
terials from the intestine. There may be headache, dulness, fretfulness, 
disturbed sleep, and associated signs of intestinal indigestion. The 
urine often contains indican in excess, and there may be slight fever. 

Diagnosis. — This includes the discovery of the cause and the principal 
seat of the constipation. To arrive at the former the most careful and 
thorough investigation should be made of the child's diet and habits. It 
is desirable to determine whether the seat of trouble is the rectum, the 
upper part of the colon, or the small intestine. If a suppository is 
almost immediately followed, by a normal stool, one may be sure that 
the rectum only is at fault, and that it needs but a little extra stimulus 
to make it do its work. This is common in infants who are too young 
to make any voluntary efforts. In such cases there are no other symp- 
toms present. In others, the white or gray stools, marked flatulence, 
offensive breath, and general irritability, leave no doubt of the fact that 
the trouble is due to indigestion. 

Treatment. — This is always difficult, and in obstinate cases must be 
continued for a long time. The co-operation of an intelligent mother 
or nurse is absolutely indispensable. To establish the habit of regular 
stools should be the first step, for without this regularity nothing can 
be done. Even in infants only a few months old proper habits are often 
easily formed if the child is put upon the chamber or chair invariably at 
the same hour. When a local stimulus is required in addition an oiled 
glass rod or a gluten suppository may be inserted. An older child must 
be taught to heed the first impulse to evacuate the bowel. Eegular 
habits can hardly be formed unless the same time each day is chosen 
for the movement. That to be preferred is soon after the morning meal, 



404 DISEASES OF THE DIGESTIVE SYSTEM. 

as taking food into the stomach usually starts a peristaltic wave which 
is continued throughout the intestine. With older children breakfast 
should be early enough to allow ample time for this duty before the 
other engagements of the day; and nurses should be impressed with 
the importance o( the early formation of proper habits on the part of 
their charges. Stretching the sphincter under an anaesthetic is some- 
times o( great benefit, especially where tonic spasm is present. 

Food. — With nursing infants who get good breast-milk constipation 
is rare. When the milk is low in fat, constipation is not uncommon. 
For the measures by which such milk can be improved, see chapter on 
Breast Feeding. 

In feeding cow's milk, constipation is overcome by getting the pro- 
portions of protein and fat which are suited to the infant. It is more 
apt to occur with infants where, on account of digestive symptoms, modi- 
fications of whole milk or skimmed milk are given instead of those 
from top-milk. The laxative effects of maltose and, to a less degree, of 
lactose, should be remembered (see Infant Feeding). With most infants 
during the first year, constipation may be, if not cured, at least pre- 
vented, by proper milk modification. 

During the second year children who suffer from constipation may be 
benefited by reducing the amount of milk and giving a limited quan- 
tity — not over three or four ounces a day — of thin cream. Improve- 
ment may often be brought about by using the coarse farinaceous foods. 
Meat broth and beef juice are quite laxative on account of their ex- 
tractives and salts. Fruits are valuable in all these cases; but only the 
juice should be given until a child is eighteen or twenty months old. 
That of almost any fresh fruit may be employed. At two years pulpy 
fruits may be given, but only after cooking; also baked apples, stewed 
prunes, and, in summer, peaches, plums, and pears, in small quantities; 
but berries should be avoided. Fresh fruits should not be given until 
after three years and then in moderate quantities only. 

For older children who are on a mixed diet the amount of starchy 
food should be moderate. Milk should be given rather sparingly. It is 
sometimes advisable to stop .milk altogether and give only cream, from 
three to four ounces of which may be allowed daily. It may be used 
with the breakfast cereal, mixed with potato or rice, added to soups or 
broths, and taken in various other wa}-s. All bread should be made from 
whole wheat or unbolted flour. Bran biscuits are also useful. Meat and 
broth may be allowed freely, also green vegetables, one of which should 
be given every day. All fruits allowed infants may be used, but in larger 
quantities, and in addition raw apples. Of the dried fruits, only dates, 
prunes, and figs are permissible, and these only after cooking. Fresh 
fruit is preferably given in the morning, oranges being especially useful 
when taken on rising. A caution is necessary in the use of fruits and 



CHRONIC CONSTIPATION. 405 

coarse foods for constipated children. It often happens that constipa- 
tion is only one of the symptoms of a chronic intestinal indigestion, and 
the use of such foods as those mentioned, while it may cause the bowels 
to move, aggravates the primary condition. They produce abdominal 
pain, flatulence, and the discharge of mucus in the stools. The admin- 
istration of some mild laxative even over a considerable period is often 
much less objectionable. 

Either hot or cold water, when taken an hour before breakfast, may 
be of considerable benefit to older children. The sparkling waters, like 
Vichy or Apollinaris, are often better than plain water. 

Massage, when properly employed, is useful in conjunction with other 
measures, but rarely succeeds alone. It should be given for five or ten 
minutes after retiring and just before rising. 

A proper amount of active muscular exercise is necessary and 
should be made a part of the treatment in every case. Yale has called 
attention to the importance of posture during the stool, he having 
found that in many cases a cure was effected simply by substituting 
a low seat on a nursery chair or closet for the high one previously 
used. 

' Suppositories. — In many cases, particularly in young infants who 
are not old enough to initiate the muscular effort, a slight stimulus to 
the rectum is all that is required. The cone of oiled paper has a great 
reputation in domestic practice and is not objectionable. It may be of 
assistance in establishing the habit of a daily movement at a regular 
time. Soap suppositories produce a more marked irritation; although 
.their immediate effect is quite satisfactory, they should not be continued 
indefinitely. They are, however, less objectionable than glycerin sup- 
positories. The latter, for an immediate effect, are convenient and 
usually efficient; but their frequent use, especially in infants, is likely 
to set up a catarrhal proctitis. The gluten suppositories produce less 
irritation and are consequently slower in their effect, but they have not 
the disadvantages of the soap or glycerin. Medicated suppositories are 
often efficient ; if drugs must be employed, they are perhaps open to the 
fewest objections when used in this way. ' The following are the best 
drugs for this purpose, the dose being that for a child of two or three 
years: ext. nux vomica, gr. -^ ; ext. belladonna, gr. -£$; ext. hyoscyamus, 
gr. -^; sulphur, gr. ij ; purified aloes, gr. J; aloin, gr. -gV- A g°°& com " 
bination is aloin, gr. -g^; ext. belladonna, gr. -^; ext. nux vomica, gr. T ^; 
ol. theobrom., gr. x. In obstinate cases this may be used night and 
morning, and later at night only. After some improvement has occurred 
the aloin may be omitted. Many of the proprietary suppositories con- 
tain the ingredients mentioned, particularly belladonna, the dose of 
which is often considerably larger than should be given. Suppositories 
are chiefly useful when the trouble is in the rectum and lower colon; 



400 DISEASES OF THE DIGESTIVE SYSTEM. 

hut very little is to be expected from them when it is higher in the 
intestine. 

Enemata. — These should he restricted to cases in which only tem- 
porary relief is desired. An injection of an ounce of sweet oil may 
facilitate the passage of very hard and dry stools, and a regular nightly 
repetition of this, or a somewhat larger amount, for several weeks will 
often break up a constipated hahit. Injections of soap and water may 
he used to soften hard faecal accumulations. For immediate effect an 
injection of one or two drachms of glycerin in an ounce of water is per- 
haps the most efficient means at our command. Cases of faecal impac- 
tion are rarely met with in children. They are to he managed as in 
adults, by repeated injections of warm water or of ox-gall, and sometimes 
by mechanical removal. For continuous use enemata of water are not 
to be advised, for larger and larger quantities are required to produce 
the effect. 

Medicinal Treatment. — This is the least important part of the man- 
agement of chronic constipation. No plan is worse than to give some 
active purgative every third or fourth day and trust matters to take 
care of themselves the rest of the time. The most valuable drugs are 
stimulating laxatives, such as cascara, nux vomica, belladonna, hyos- 
cvamus, and phenolphthalein. These are particularly useful in atonic 
constipation associated with rickets and following diarrhceal diseases, but 
they are valuable in all cases. With most drugs the prolonged use of 
small doses is better than the occasional use of large ones. Calomel is 
indicated in cases attended with dry, very white stools and marked flatu- 
lence; one-fourth to one-half grain of the tablet triturates may be given 
for two or three successive nights in conjunction with other means. 
Cascara may be used either in the form of the elixir, dose from one-half 
to one drachm, or the fluid extract, from one to five drops. Ehubarb, 
either in the form of the syrup or the mixture of rhubarb and soda, may 
be given occasionally, but it is not adapted to continuous use. Of 
salines, magnesia and phosphate of soda are best for continuous use in 
infants. All the preparations of malt possess slight laxative properties, 
and are useful in conjunction with dietetic and other medicinal means; 
any of the extracts of malt may be employed. Castor oil should seldom 
be given for chronic constipation. Olive oil is often of assistance in the 
treatment of the constipation both of infants and older children. To the 
former the usual dose is one teaspoonful three times a day ; to the latter, 
two or three times this amount should be given. Agar-agar by rendering 
the faecal mass softer and more easily expelled frequently proves a most 
effective remedy for older children. It should be broken up into fine 
fragments and mixed with the cereal when eaten or it may be cooked 
with it. The dose is three or four teaspoonfuls. 



INTUSSUSCEPTION. 407 

HYPERTROPHY AND DILATATION OF THE COLON 

(Hirshprung' 's Disease). 

It is probable that in many cases of chronic constipation, especially 
among rachitic infants, a considerable degree of dilatation of the colon 
occurs. However, it seems to be but a temporary condition, disappearing 
by the third or fourth year. 

There is another form of dilatation which may be permanent and is 
generally believed to be of congenital origin; it is associated with a 
marked degree of hypertrophy of the muscular walls of the colon. Cases 
have been observed both in infants and in older children. The prom- 
inent symptoms are two: obstinate constipation, which in most of the 
cases has continued from early infancy, and is sometimes so severe that 
the patients have gone for two weeks without a movement of the bowels ; 
and distention of the abdomen, which may be extreme, but which may 
disappear and the abdomen become perfectly flat after the faeces and 
flatus have been discharged. There is usually emaciation, and from time 
to time there may be diarrhoea. Death may occur in infancy, or the 
patients may live to adult life. 

In the cases which have come to autopsy there has been found an 
enormous dilatation of the large intestine, chiefly of the transverse colon 
and the sigmoid flexure. In one reported case, in a boy of three years, 
the colon was four inches in diameter, and held fourteen pints of water. 
In none of the cases was there stricture at any point. The mucous mem- 
brane has almost invariably been found ulcerated, this clearly being a 
secondary process. The muscular walls have been greatly hypertrophied. 
Medical treatment is palliative only. An artificial anus has been made 
in several cases with at least temporary benefit. The complete removal 
of the large intestine has also been performed for this condition. 

INTUSSUSCEPTION. 

Intussusception consists in the invagination of one portion of the 
intestine into another. It occurs most frequently in infancy, being at 
this age the most common cause of acute intestinal obstruction. The 
accident is not a common one, but the life of the patient generally de- 
pends upon its prompt recognition. 

Varieties. — Usually the upper part of the intestine is invaginated into 
the lower, although the reverse is occasionally seen. Intussusceptions 
may occur at any point in the intestinal tract. Those of the small intes- 
tine are called enteric; those of the colon, colic; and those occurring at 
the ileo-caecal valve, ileo-ccecal (Fig. 65). Of 90 cases under ten years 
of age, in which the variety was determined by autopsy or operation, 75 
were ileo-caecal, 9 colic, and 6 enteric. In the ileo-caecal form a few 



408 DISEASES OF THE DIGESTIVE SYSTEM. 

inches of the ileum pass through the ileo-caecal valve, and then invagina- 
tion of the colon occurs. Cases in which the ileum passes through the 
valve, but without invagination of the colon, are sometimes classed sep- 
arately as an ileo-colic variety. 

Intussusceptions of the dying, as they have been called, are met with 
in my experience in about eight per cent of all autopsies made upon 




Fig. 65. — Ileo-caecal Intussusception. 
A specimen removed from a child in the New York Infant Asylum. 

infants; they are not often found in children over two years of age. 
They are descending, enteric, easily reducible, and multiple — usually 
from eight to twelve invaginations are present. They are more fre- 
quently in the jejunum than in the ileum. They usually involve but 
two or three inches of the intestine, but may include ten or twelve 
inches. They are found in autopsies upon patients dying of all varieties 
of disease, and are probably produced in the death agony. Such intus- 
susceptions are without symptoms, and are of no clinical importance. 

Etiology. — Of 358 collected cases under ten years, the following are 
the ages reported : under four months, 28 cases; from four to six months, 
113; seven to nine months, 71; ten to twelve months, 18; one to two 
years, 32 ; two to ten years, 06. Three-fourths of the cases which occur 
in childhood are, therefore, in the first two years, and one-half of them 



INTUSSUSCEPTION. 409 

between the fourth and ninth months. The greater frequency in infancy 
is attributed to the thinness of the intestinal walls, the greater mobility 
of the caecum and ascending colon, and the presence of other intestinal 
derangements at this age. 

Males are more often affected than females. Of 268 cases in which 
the sex was mentioned, there were 174 males and 94 females. For this 
fact there is no explanation. The exciting causes of an attack are ex- 
tremely obscure. The great majority of cases occur in children who were 
apparently in perfect health. Some previous intestinal disorder was 
present in about three per cent of the cases I have collected — diarrhoea, 
dysentery, colic, chronic indigestion, and constipation, all being men- 
tioned. In four cases the intussusception was ascribed to injury of the 
abdomen. The association with the general diseases is too infrequent to 
be of any importance. 

Lesions. — Nothnagel's animal experiments have shown conclusively 
that intussusceptions are formed by the irregular action of the muscular 
walls of the intestine. They can be produced or released at will by vary- 
ing the application of the electrical current. In the artificial intussus- 
ception there is first a contraction of a certain part of the intestine, and 
if this ceases abruptly the normal gut below this point turns upward and 
folds over upon the contracted portion, thus forming a minute intus- 
susception (Fig. 66, A). When once began, the intussusception in- 
creases solely at the expense of the external layer (Fig. 6G, B). Thus, 
while the apex of the tumour D remains unchanged, the part of the 
sheath at A passes to B and then to C, so that the lower part of the 
intestine is drawn over the upper, rather than the upper crowded into 
the lower. The mechanism of the invagination was apparently the same 
when a part of the intestine was 

first paralysed by crushing, as in 

the cases in which a spasm of the ___ 7/ ■ 

intestine was first produced. Fig. 66, A. 



Fig. 66, B. — Mechanism of Intussusception. (Treves.) 

There is little doubt that pathological intussusceptions are produced 
in the same way as in these experiments. As the invagination takes 
place, the mesentery is drawn in with the bowel, and always lies between 
the sheath and the inner layer. To allow intussusception to occur, the 
mesentery must be unduly long, stretched, or lacerated. Its attachment 
to the spine causes the intussusception to describe an arc of a circle, the 
concavity of which is always toward the spine. It also causes a puckering 
of the tumour. Invagination does not necessarily produce either ob- 



410 DISEASES OF THE DIGESTIVE SYSTEM. 

struction or strangulation, but usually both are present, and are the 
chief causes of the symptoms. Traction upon the mesentery leads to 
obstruction in its vessels, causing congestion, oedema, haemorrhages, and 
even gangrene. Obstruction is chiefly due to swelling. It may be due to 
dragging of the mesentery, which brings the apex of the tumour against 
the side of the gut, or to bending of the intussusception. Intussusception 
is usually of all the coats of the intestine. I have, however, seen one, 
the exact nature of which was determined by operation, in which only 
the mucosa and submucosa were involved. The invagination was at the 
ileo-ca^cal valve. The symptoms were characteristic except for the ab- 
sence of tumour. 

The great cause of irreducibility in the first two or three days is 
swelling. I have several times seen at autopsy or operation the intus- 
susception easily reduced, except the last two or three inches of the 
caecum or ileum, which was swollen to the thickness of from a fourth 
to half an inch. Adhesions may prevent reduction, but rarely before the 
fourth day; they are often absent as late as the sixth or seventh day. 
They are usually between the internal and middle layers of the intus- 
susceptum, and are due to local peritonitis. In chronic cases, however, 
they form the principal obstacle to reduction. Other causes of irreduci- 
bility are twisting of the tumour and pinching of the prolapsed intestine, 
especially of the ileum by the ileo-csecal valve. 

Gangrene and sloughing of the gangrenous portion of the intestine 
occur much more often in acute than in chronic cases. Portions of 
intestine were passed per anum in 24 of 362 cases under ten years, or 
about six per cent; but only two of these were in infants. Toward the 
end of the second week is the time when the separation of the sloughs is 
to be looked for. The amount of intestine discharged varies from a few 
inches to several feet. Two cases are on record in which the entire colon 
was passed, the patients recovering, but dying several months later from 
other causes. At the autopsies the ileum was found attached to the lower 
part of the rectum just above the anus. In acute cases gangrene occurs 
about the upper end of the tumour, and the intestine usually comes away 
in one large mass. In chronic cases shreds of intestine may be discharged 
for several weeks. 

Symptoms. — The clinical picture of a case of intussusception is a 
striking one, and when acute the symptoms are so uniform that, once 
seen, it can scarcely be overlooked a second time. The patient, usually 
between six and twelve months of age, is taken suddenly ill with severe 
pain and vomiting; the pain recurs paroxysmally every few minutes, 
and the vomiting being first of the contents of the stomach, and after- 
ward bilious. There may be one or two loose fa?cal stools, then only 
blood or blood and mucus are passed without any admixture of faeces. 
The general symptoms are those of great prostration, or even collapse — 



INTUSSUSCEPTION. 41 1 

pallor, feeble pulse, apathy, and normal or subnormal temperature. The 
abdomen is relaxed. A tumour is present in the left iliac fossa, or it 
may be felt per rectum. Later there is tympanites; the vomiting and 
pain continue; there is a steady increase in the prostration, and toward 
the end. a rapidly rising temperature which may reach 105° or 106° F. 
before death occurs from collapse. If the symptoms continue longer the 
signs of peritonitis are added. In subacute cases the onset is less 
abrupt, and pain, vomiting, and constipation less constant and less severe ; 
but the same symptoms are present. In chronic cases the onset is with 
vague, indefinite intestinal symptoms; pain, vomiting and bloody dis- 
charges are usually wanting; there is progressive wasting and more or 
less diarrhoea, but only the presence of the tumour leads to the recogni- 
tion of the condition. 

In subacute or chronic cases the diagnosis is much more difficult. 
The general symptoms may be wanting entirely. Vomiting is usually 
absent; constipation is less marked and there may be none. The only 
diagnostic feature is the presence of the tumour, usually accompanied 
by evidences of catarrhal colitis, discharge of mucus, etc. 

Onset. — Of 193 cases under ten years in which data upon this point 
could be obtained, the onset was sudden in 181 and gradual in 12 cases. 
By far the most frequent symptoms of onset are pain and vomiting. In 
a smaller number of cases the initial symptom is diarrhoea or a dis- 
charge of blood and mucus. 

Pain. — This is rarely continuous, but is intermittent, recurring in 
paroxysms like those of ordinary colic, but of great severity. No pain in 
infancy is to be compared with it. The child sometimes shrieks so as to 
be heard all over the house. Pain is a prominent symptom in over three- 
fourths of the cases, and is very rarely absent. It is generally more 
marked for the first two days, but may continue throughout the attack. 
In a few cases the pain is localised, being usually referred to the region 
of the umbilicus. 

Vomiting is more marked at the onset, but may continue throughout 
the attack. Like the pain, it is more frequent in the acute cases. It is 
due to intestinal obstruction. Vomiting is present in fully four-fifths 
of all cases. Usually it is persistent and often projectile. If food is 
given, vomiting often occurs as soon as it reaches the stomach. Stercora- 
ceous vomiting occurs in about fifteen per cent of the cases in children 
under ten years, but is not common in infancy. It is rarely present 
before the third or fourth day. Although a bad sign, it is not by any 
means a fatal one, as nearly one-half the cases in which it has been noted 
have recovered; it is to be regarded as indicating complete intestinal 
obstruction rather than strangulation. 

Tumour. — This is one of the most important symptoms for diagnosis 
because of its frequency and its peculiar character.. It is present early in 



412 



DISEASES OF THE DIGESTIVE SYSTEM. 



the disease, often in a few hours after the initial symptoms. The follow- 
ing table shows the frequency with which a tumour was present in the 
different varieties, and the position which it occupied in each. The 
anatomical variety was determined either by autopsy or operation. 

The Relation between the Tumour and the Different Varieties of Intussusception 
in 188 Cases under Ten Years. 





Seat of Intussusception. 


Seat of Tumour. 


Ileo- 
cecal. 


Ileo- 
colic. 


Colic. 


Enteric. 


Not 
stated. 


Total. 


Region of caecum 

" " ascending colon 
" " transverse colon 
" " descending colon 
" " sigmoid flexure . 

Rectum 

Protruding from anus .... 

Umbilical region 

Movable 


1 
3 
3 
4 
25 
9 

1 


3 

i 


1 

7 
1 


1 

1 
1 


7 

12 
13 
18 

8 
28 
12 

2 


11 

13 
16 
21 
13 
61 
22 
1 
3 


Site unknown 


1 






Total 

Xo tumour felt 


46 
10 


4 
2 


9 


3 
1 


100 
13 


162 
26 







Tumour was thus made out during life in eighty-six per cent of the 
cases; and in the great majority of these it was discovered at the first 
careful examination. 

It will be noted that in one-half of the cases the tumour was either 
felt in the rectum or protruded from the anus, and that in over two- 
thirds it had advanced as far as the descending colon or beyond. The 
tumour may reach the rectum in a surprisingly short time, even when 
the invagination begins at the ileo-caecal valve. In one of my own cases 
it was felt in the rectum in less than twelve hours from the onset. The 
usual description, " sausage-shaped/ 7 is accurate when the invagination 
is large, the tumour then being from four to six inches long and about 
an inch and a half in diameter. It is often curved. 

During manipulation, or during an attack of pain, the tumour may 
become more prominent and may be distinctly erectile. To the touch 
the rectal tumour closely resembles the os uteri, the central opening being 
the apex of the intussusception. When protruding from the body, the 
tumour is rarely more than two inches long. It is usually of a deep 
purplish colour, and may be gangrenous. It has been mistaken for 
prolapsus ani, polypus, and even haemorrhoids. In a case which came 
subsequently under my observation, the tumour was discovered by the 
mother before the physician had suspected the condition. 

Condition of the Bowels. — Bloody stools are a very constant symp- 
tom. Of 186 cases under ten years in which this condition of the bowels 



INTUSSUSCEPTION . 413 

was noted, blood in the stools was present in seventy-six per cent. There 
are very often two or three thin, diarrhoeal movements, and then only 
blood and mucus are passed with no trace of faeces and with no faecal 
odour. The amount of blood varies from a quantity sufficient to stain 
the mucus, to an ounce of semi-fluid blood. It rarely occurs without 
some mucus. Such discharges frequently follow attacks of severe colicky 
pain, and may occur several times in an hour. They may continue, or 
after a day or two they may be succeeded by absolute stoppage. Diar- 
rhoea throughout the attack is rare in children, particularly so in in- 
fants. It belongs generally to chronic cases. Constipation is complete 
in most of the acute cases, neither gas nor faeces being passed ; a fact 
which the discharge of blood and mucus may lead one to overlook. 

Tenesmus is very common if the tumour is rectal. Relaxation of the 
sphincter is met with in a considerable proportion of the cases when the 
tumour is in the sigmoid flexure, or. rectum. 

During the first twenty-four or forty-eight hours the abdominal walls 
are soft and relaxed, and may even be retracted. Usually there is then 
little resistance to abdominal palpation. After the second or third day 
there is usually tympanites; but this does not necessarily mean that 
peritonitis exists. Localised tenderness is a symptom of some impor- 
tance when a tumour is absent. Scanty urine has been noted in a few 
cases, but is of no special value in showing the seat of obstruction. 

In the acute cases the general symptoms are very striking. They are 
the ordinary ones of severe shock — marked prostration, pallor with an 
anxious expression of the face, general muscular relaxation, cold extrem- 
ities, cold perspiration, and often a subnormal temperature. Early there 
is marked restlessness, and even convulsions may occur. Later there are 
apathy, dulness, and semi-stupor. The temperature during the first 
twenty-four hours is usually not elevated, and is frequently subnormal. 
Toward the close of the disease it rises rapidly to 103°, 104° F., or even 
higher, quite independently of peritonitis. A rapidly rising temperature 
is always a bad symptom, and usually betokens death within twenty- 
four hours. Wasting is seen in the chronic cases, and may be quite 
rapid. 

Course, Duration, and Termination. — Of 198 cases under ten years, 
155 were classed as acute, lasting less than seven days; 33 as subacute, 
lasting from one to four w r eeks; 10 were chronic, lasting over four weeks. 
Nearly all the cases occurring in infancy are acute. 

Spontaneous reduction is, without doubt, possible in intussusception. 
Treves and others are of the opinion that this happens much more fre- 
quently than is generally supposed, and that many cases of severe colic 
are really cases of slight intussusception. There are seen in both con- 
ditions the tendency to vomit, the paroxysmal pain, the constitutional 
depression, and often the sudden cessation of the symptoms, especially 



414 DISEASES OF THE DIGESTIVE SYSTEM. 

under the influence of opium ; but to make a positive diagnosis of invagi- 
nation in such cases is impossible. Intussusception may be cured spon- 
taneously by sloughing of the invaginated part, the continuity of the 
intestine being preserved by adhesions. Such a result is rare at all ages, 
and is almost never seen in infancy. 

The most frequent cause of death in acute cases is shock. Peritonitis 
is not found at autopsy or operation so often as might be expected. In 
fifty-eight autopsies, it was seen but twenty times, and in seven of these 
it was limited to the intussusception. In but seven cases was there per- 
foration. 

Diagnosis. — This usually presents no difficulty in acute cases provided 
the physician has the condition in mind. The great majority of such 
cases present nearly all the classical symptoms, viz., sudden onset, recur- 
ring colicky pains, frequent vomiting, bloody and mucous stools without 
faecal matter, general prostration or collapse, and low temperature. The 
records show that the most common error is to regard the case for the 
first few days as one of gastro-enteritis or ileo-colitis, the physician's 
attention being engrossed by the vomiting and bloody stools. Given 
the other usual symptoms, the presence of the characteristic tumour is 
conclusive evidence of intussusception. Unless the patient is very much 
relaxed, a satisfactory examination is possible only under full anaesthesia. 
In any case of acute intestinal obstruction in infants, intussusception 
should first be considered. I once saw, in a young infant, strangulated 
hernia produce nearly every symptom of intussusception except the 
abdominal tumour. Chronic cases present no diagnostic symptoms 
except the tumour. In both acute and chronic cases the rectal exami- 
nation is most important for diagnosis, and often settles the question 
at once. 

Prognosis. — The prognosis of intussusception depends upon the age 
of the patient, upon the variety of the disease — whether acute, subacute, 
or chronic — and upon the time when proper treatment is begun. 

There were collected by Pilz in 1870, 94 cases under one year, the 
mortality being 84 per cent. Of 135 cases of the same age reported 
between 1870 and 1891 the mortality was 59 per cent. Eesults in older 
children were somewhat more favourable. Formerly recovery was rare, 
except in cases with sloughing; but with earlier diagnosis and a better 
understanding of the proper methods of treatment, the mortality has 
been very much reduced. Combining the figures of Pilz with my own, 
there are 362 cases with 231 deaths, or 63.5 per cent. 

Gibson (New York) has collected reports of 187 operations for intus- 
susception, with a general mortality of 51 per cent; in 126 cases, in 
which the tumour was reducible, it was but 36 per cent ; in 61, in which 
it was irreducible or gangrenous, it was 80 per cent. The table following 
gives the mortality in relation to time of operation: 





APPENDICITIS. 


415 


Time op Operation. 


Mortality. 
Per cent. 


First day 


37 


Second " 


39 


Third " 


61 


Fourth " 


67 


Fifth " 


73 


Sixth " 


75 







After the second day the chances of success are greatly reduced. 

Treatment. — The diagnosis of acute intussusception once made, lapa- 
rotomy should immediately be performed without an hour's unnecessary 
delay. The results following inflation of the intestine with air and 
injection with water are too uncertain to be depended upon. 

Operation should be looked upon as a measure which, if employed 
reasonably early, offers a good prospect of success. All statistics show 
that the result depends more upon the time when the operation is done 
than upon any other single factor. With earlier diagnosis and more 
prompt resort to operation, the mortality from acute intussusception has, 
during the past fifteen years, been steadily falling. In chronic cases, 
also, laparotomy offers altogether the best chance of success. 



CHAPTEE IX. 
DISEASES OF THE INTESTINES.— (Continued). 

APPENDICITIS. 

Appendicitis is met with at all ages, and is not especially a disease 
of children. When it attacks those over ten or twelve years of age it 
does not differ greatly from the types observed in adults. All that will 
be attempted in this chapter will be a consideration of the peculiarities 
of the disease as it is seen in children, particularly young children. For 
a fuller discussion of the disease as a whole the reader is referred to 
works on general medicine and surgery. 

Etiology. — Of 1,000 cases of appendicitis personally observed by 
McCosh, 85 occurred in children between the ages of ten and fifteen 
years; 51 between the ages of five and ten years, and only 17 under five 
years ; of these but 4 were under two years. Churchman's figures from 
the Johns Hopkins' Hospital, in a total of 1,223 cases, give only 9 cases 
under five years, and 50 between five and ten years. In infancy and 
early childhood appendicitis is, therefore, a relatively rare disease. The 
youngest cases that have come under my observations were in infants of 
nine and fourteen months respectively. Goyen's case was in an infant 



41(3 DISEASES OF THE DIGESTIVE SYSTEM. 

only six weeks old; Shaw's, seven weeks; Demme's, seven w T eeks; and 
Savage's, nine weeks old. The predominance of the male sex holds true 
even in childhood. Of 101 eases under fifteen years, 72 were males and 
89 were females. 

Regarding the exciting cause of an attack but little is yet definitely 
known. In only a very small proportion of the cases is a foreign 
body discovered in the appendix. In one of my own a pin was found, 
and a number of similar cases are on record. There is, however, almost 
invariably a faecal concretion which is moulded into the shape of a for- 
eign body, and formerly was often regarded as such. This probably has 
some relation to the attack by causing disturbances of circulation and in- 
creasing the chances of infection. Still and others have called attention 
to the frequent occurrence of pin worms in the appendices of young chil- 
dren. There is abundant reason for believing that these may at times 
be the exciting cause of an attack. The bacteria most frequently found 
in abscesses from appendicitis are streptococci, usually associated with 
colon bacilli. 

Lesions. — All the common varieties of acute appendicitis, the catar- 
rhal, suppurative, and gangrenous, are met with in children ; and, much 
less frequently, the chronic form. The lesions present few peculiarities 
in early life except that, owing, possibly, to the relation of the appendix 
to the omentum, perforative inflammations are less likely to be circum- 
scribed by inflammatory products and much more likely to result in a 
general peritonitis than in adults. Whether or not this be the correct 
explanation, it is certainly true that general peritonitis is a much more 
common sequel than in adults. Another point of some importance is 
the fact that in early life the appendix is rather more frequently found 
out of the usual position. The inflammation excited by pin worms is 
usually a superficial one; perforation and abscess formation are almost 
unknown when they are the cause. 

Symptoms. — In many of the cases the familiar symptoms of appen- 
dicitis — vomiting, localised pain and tenderness, muscular rigidity, ab- 
dominal distention, and fever — are all present, and the diagnosis is easy. 
But in perhaps the larger number the disease is irregular in its onset, 
insidious in its course, and presents at times great difficulties in diagnosis. 
This is particularly true of appendicitis in children under five years. 
Vomiting is probably the most constant symptom; it is seldom absent, 
and usually persistent. If accompanied by pain and constipation, ap- 
pendicitis should at once be thought of. Pain, though usually present, is 
often indefinite ; it is generally hard to localise and difficult to interpret. 
It may be referred now to one and now to another part of the abdomen. 
Often the only evidence of pain is restlessness, irritability, and, in in- 
fants, frequent crying. Tenderness is even more difficult to elicit than 
pain. Young children, especially if nervous and sensitive, shrink from 



APPENDICITIS. 417 

any touch, and the results of abdominal palpation may be most unreli- 
able. In others of a different temperament positive information may be 
obtained. In any child under three years, it is practically impossible to 
make out localised tenderness. The same is true of muscular rigidity. 
Only with the greatest amount of tact and by diverting the patient's 
mind, can any information be derived from this part of the examination. 
Tenderness and muscular rigidity are sometimes shown by the child's 
disinclination to move either the trunk or lower extremities and by evi- 
dences of pain when he is moved by mother or nurse. When associated 
with vomiting, fever, and constipation, such symptoms are always sug- 
gestive. 

Constipation is usually present, but by no means so regularly as in 
adults. Diarrhoea is not at all uncommon, and, when associated with 
vomiting, tends to divert attention from the appendix to an ordinary 
gastro-intestinal attack. Abdominal distention, when present, is of much 
importance, taken with other symptoms. Fever is rather more apt to 
be high than in adults. But there are many exceptions, and, on the 
whole, the temperature is a very untrustworthy guide either to diag- 
nosis or prognosis. The leucocyte count is of much assistance in diagno- 
sis, at least in suppurative forms of appendicitis. A leucocytosis of at 
least 10,000 to 20,000 is usually present, with a polymorphonuclear per- 
centage over 75. Some special symptoms may be seen in appendicitis 
which are quite misleading. I have on several occasions seen frequent 
micturition and other marked manifestations of vesical irritation, ow- 
ing to the position of the appendix behind the bladder. The rigidity 
of the thigh flexors seen in cases of appendicitis, which come on with 
subacute symptoms, may give rise to lameness strongly suggestive of hip 
disease; cases of this kind are not infrequently seen at the Hospital for 
Ruptured and Crippled. 

Course of the Disease. — A certain number of cases begin with definite 
symptoms — pain, vomiting, fever, and constipation — and continue with 
slowly or rapidly advancing symptoms to increasing prostration, con- 
tinued vomiting, constipation, rapid pulse, abdominal distention, and 
rigidity, higher temperature, and death by general peritonitis at the 
end of five or seven days' illness. Others, with a similar onset, show a 
gradual abatement of all acute symptoms after a few days, and recovery 
at the end of ten days or two weeks, followed, perhaps, by another at- 
tack after a few months. These types are seen in children as in adults. 
But others are quite common. A child may be taken ill, sometimes 
abruptly, sometimes more gradually, with vomiting, which is repeated 
several times in a single day, afterward only occasionally. There is 
some pain; it is not very definite and not localised. The prostration is 
only moderate, the temperature not over 100° or 100.5° F. The examina- 
tion shows little. Tenderness can not be definitely made out; the child 
28 



41 S DISEASES OF THE DIGESTIVE SYSTEM. 

is irritable, fretful, wishes to be left alone, and resists all efforts at ab- 
dominal palpation. The bowels are constipated, or they may be at first 
loose and afterward constipated. The child does not seem very sick. 
The attack is probably regarded as an ordinary one of acute indigestion. 
But things do not improve as they ought. The pulse becomes more 
rapid, the prostration greater, and the child begins to look seriously ill, 
though the temperature has not risen. The abdominal distention is now 
considerable and tenderness undoubted. An operation is decided on, and 
there is found a gangrenous appendix and a diffuse general peritonitis. 
Sometimes the grave symptoms develop with great rapidity in the course 
of a few hours, when previous symptoms had all been mild; sometimes 
so insidiously that the transition is almost imperceptible. 

Prognosis. — The prognosis in young children is not good; of 132 
collected cases in infants and very young children the mortality was 38, 
per cent. But in those over seven years old the outlook is rather better 
than in adults. The results depend much upon early diagnosis and 
proper treatment. General peritonitis, it is generally agreed, occurs 
much of tener in children than in adults ; it is the cause of death in about 
80 per cent of the cases. Of 43 fatal cases, nearly all of them from gen- 
eral peritonitis, only 6 died during the first three days, 19 from the 
fourth to the seventh day, 13 in the second week, and 5 in the third 
week. If general peritonitis occurs, the chances of recovery after opera- 
tion are, however, better with children than with adults. 

Diagnosis. — The diagnostic symptoms of appendicitis are a sudden 
onset with vomiting, sharp pain in the abdomen, and persistent acute 
localised tenderness in the right iliac fossa. Rigidity of any or all of 
the abdominal muscles is also significant. Constipation is more fre- 
quent than diarrhoea, though the latter is not rare. There is almost 
invariably some elevation of temperature, but not often high fever. 

Appendicitis may be confounded with colic, indigestion, and in in- 
fants with intussusception; in older children with abscesses due to pso- 
itis. Colic is distinguished by the absence of localised tenderness and 
fever, by its short duration, and by the fact that the pain is generally 
less intense. Severe colic with fever in children over three 3 r ears old 
should, however, always be regarded with suspicion. From acute indi- 
gestion the diagnosis of appendicitis is difficult at the onset, and it may 
be impossible for twenty-four hours. However, the pain of indigestion 
is rarely so severe, while the fever is usually higher. It should be re- 
membered that the pain in appendicitis is not always localised, nor is the 
tumour always in the right iliac fossa. The presence of pain, vomiting, 
and localised tenderness, and the greater severity of the constitutional 
symptoms, indicate appendicitis. I have several times known the 
pleurisy accompanying pneumonia at the right base to be mistaken for 
appecdicitis. With this there may be vomiting, severe localised pain, and 



INTESTINAL WORMS. 419 

sometimes also localised tenderness. Cyclic vomiting is distinguished by 
the history of previous attacks, the greater frequency with which the 
vomiting occurs, its abrupt cessation after twenty-four to forty-eight 
hours, the sunken abdomen, and the absence of pain, tenderness, and 
rigidity. The presence of early acetonuria is also characteristic. Intus- 
susception, with its pain, colic, and vomiting, may suggest appendicitis, 
but is very rare, except in infants. Fever is absent early in the disease, 
and a tumour is usually present. Acute or subacute suppuration in the 
right iliac fossa is almost invariably due to appendicitis. 

The leucocyte count may be of considerable assistance in differentiat- 
ing appendicitis from colic, cyclic vomiting, ileo-colitis, and intussus- 
ception. It should, however, be remembered that in some of the gravest 
cases the leucocytosis may be slight or there may be none at all. On 
the whole, while the presence of marked leucocytosis — i. e., above 20,000 
— may be of considerable assistance in the diagnosis, no inference can 
be drawn from a normal count or a slight leucocytosis if the child is 
greatly prostrated. Whenever, in children over two years old, there are 
symptoms pointing to acute peritonitis, no matter what their combina- 
tion or variety, appendicitis should always be suspected. 

Treatment. — Absolute rest in bed can not be too strongly insisted 
upon whenever appendicitis is suspected, no matter how mild the attack 
may appear. As a local application, the ice-bag is to be preferred. 
Opium should not be given. It does harm by obscuring important 
symptoms and increasing constipation. The colon should be kept empty 
by the daily use of enemata. After a thorough clearing of the bowels 
in the beginning, preferably by a saline, cathartics are to be avoided. 

Appendicitis is a surgical disease, and surgical advice should be 
sought early. In deciding as to the time of operative interference, it 
should be remembered that the natural course of the disease in children 
is much less likely to be favourable than in older patients; that the 
dangers of general peritonitis are much greater ; that the progress of the 
disease is much less regular; that grave conditions are not revealed at 
once by grave symptoms; that the disease is an insidious one, and that 
to foretell the outcome even in the mildest cases is impossible. Taking 
all these things into account, I believe that immediate operation, once 
the diagnosis is made, is the course to be recommended in all cases of 
acute appendicitis in children. The younger the child the greater the 
urgency for operation. 

INTESTINAL WORMS. 

Judging by published reports, intestinal worms are much more com- 
mon in Europe than in this country. In 10,000 patients treated for 
medical diseases in my dispensary service, there was positive evidence of 
worms in but 79 cases. Of these, 9 had tapeworms, 40 roundworms, 27 



420 DISEASES OF THE DIGESTIVE SYSTEM. 

threadworms, and 3 both round and threadworms. In private practice 
among the hotter classes, worms are certainly rare. 

Cestodes — Tapeworms. — Cestodes are usually introduced into the 
body hv the ingestion of some form of food containing larvae (cysticerci). 
The larva of the taenia solium is most frequently found in pork; that of 
the tenia mediocanellata in beef; that of the bolhriocephalus latus in 
fish; that of the taenia cucumerina inhabits dog or cat lice, being intro- 
duced into the intestinal tract accidentally by the hands. Several vari- 
eties of taenia are found in the human intestine. 

Taenia Sagixata or Mediocanellata — Beef Tapeworm. — Infec- 
tion results from eating raw or partially cooked beef containing cys- 
ticerci. The worm is from twelve to twenty feet in length, and has a 
square pigmented head without hooks but provided with four suckers. 
The full-sized segments are from one-half to three-fourths of an inch 
long and about half as wide. 

Taenia Solium — Pork Tapeworm. — This is a rare form in chil- 
dren, and comes from eating raw or partially cooked pork or sausage. 
It is from six to ten feet in length, the segments being nearly square. 
The head is about the size of a mustard seed and is pigmented. It also 
is provided with four suckers and a proboscis, surrounding which is a 
circle of about twenty-six hooklets. 

T.exia Cucumerina or Elliptica. — The larvae of this form develop 
in a louse found on the skin of dogs and cats. Children who play with 
infected animals are the ones affected, the parasite being conveyed to 
the mouth usually by means of the hands; it may thus be found even 
in young infants. This form of taenia is much smaller than either of 
the preceding varieties, the full length being only from six to twelve 
inches. 

Bothriocephalus Latus. — This is a rare form except in the sea 
countries of northern Europe and Switzerland, where it is said to be 
very common. The larvae are harboured by certain fish, through which 
they are introduced into the body. The full-grown worm is from twenty- 
five to thirty feet in length. 

Tjexia Xaxa. — The taenia nana, or dwarf tapeworm, is the smallest 
of all the cestodes. It is a narrow worm of one-half to three-fourths of 
an inch in length, and is composed of one hundred to two hundred 
segments. It has a slender neck and globular head which contains four 
suckers and twenty or thirty hooklets. The habitat of the nana is the 
upper part of the ileum where it is often found in immense numbers. 
A single stool may contain several hundred worms. The ova have two 
definite membranes within the inner one of which three pairs of hook- 
lets are found. The cysticercus stage of this parasite is not known. 
It is probable that infection occurs from swallowing the ova them- 
selves. As a similar parasite inhabits the intestinal tract of rats and 



INTESTINAL WORMS. 421 

mice it is possible that these animals play a part in transmission. 
From the observations of Schloss it seems probable that in the vicin- 
ity of New York this is the most frequent intestinal parasite of 
childhood. 

Symptoms. — The only positive evidence of tapeworm is the discharge 
of the worms or separated segments, either singly or in groups. Occa- 
sionally worms pass into the stomach and are vomited. Various abdomi- 
nal symptoms may be associated with worms, but most of these are very 
indefinite in character and are more often due to other causes. The 
most frequent symptoms are bad breath, various annoying sensations, 
colicky attacks, inordinate or capricious appetite, and diarrhoea. Usu- 
ally, if the patient is in good health, no constitutional symptoms are 
seen. Sometimes, particularly with the bothriocephalus latus, there is a 
very grave degree of anaemia. The increase in the number of eosinophile 
cells in the blood is of considerable diagnostic value. They generally 
form from four to ten per cent of the leucocytes, while in normal blood 
the usual number is less than two per cent. Many cases are on rec- 
ord, some of them in children, in which the symptoms of pernicious 
anaemia have been present and have disappeared after the expulsion of 
the tapeworm. Nervous symptoms are not so often seen as with round- 
worms, and will be discussed in connection with them. 

Treatment. — Prophylaxis requires the cooking of meat to a suf- 
ficient degree to destroy the cysticerci. There is especial danger in 
eating raw pork or sausage; that from rare beef is much less. The list 
of drugs used for the expulsion of the worm is a long one ; probably 
the most efficient is the oleoresin of male fern ; it is, however, difficult to 
administer and it is very likely to provoke vomiting. It may be given 
in capsules containing Tl\x to TT^xx, or in an emulsion made up with 
simple elixir and acacia, in which TTLv to u\x are contained in one 
drachm. For a child of four years at least one drachm of the male fern 
should be given in the course of six to eight hours. The vermifuge 
should be preceded by several hours' fasting, and the bowels previously 
opened by a laxative. The following plan of administration has been 
found satisfactory : A light supper of milk, and in the morning a saline 
laxative on rising, but no breakfast; after the saline has acted freely 
the remedy is to be given, and following the last dose, half an ounce of 
castor oil or some other active purge. The effect of the cathartic is 
aided by a large injection of warm soap and water. Only milk should 
be given that day. The fragments passed should be carefully examined 
to see if the head has been expelled, as the worm is very likely to be 
broken at the neck. If this occurs it will grow again, and in about 
three months segments will appear in the stools. Other drugs useful 
for taenia are pumpkin seeds which are given in powdered form, infusion 
of pomegranate root, turpentine, and chloroform. 



422 



DISEASES OF THE DIGESTIVE SYSTEM. 



Nematodes. — Throe varieties are found in the intestinal canal, the 
ascaris lumbricoides, the oxyuris vermicularis, and the uncinaria Amer- 
icana. 

Ascaris Lumbricoides — Roundworm. — This worm is usually found 
in the small intestine. It is much more frequently met with in children 
than is the tapeworm. It is exceedingly rare in infancy, but is usually 
seen between the third and tenth years. In over one thousand autopsies 
upon infants I have only once found a roundworm in the intestine. 

The roundworm resembles the ordinary earthworm; it is from five 
to ten inches long, the female being longer than the male. It is of a 

light gray colour with a slightly pinkish tint, 
cylindrical, and tapering toward the extrem- 
ities (Fig. 67). The eggs are oval in form, 
about ^Q- mcn i n diameter, and numbered by 
millions. These worms rarely exist singly; 
usually from two to ten are present, but there 
may be hundreds. When very numerous they 
coil up and form large masses, which may 
cause intestinal obstruction. 

The migration of these worms is curious, 
and in some instances truly remarkable. They 
frequently enter the stomach and are vomited. 
Occasionally one may appear in the nose. 
They have been known to pass through the 
Eustachian tube into the middle ear and to 
appear in the external meatus. Entering the 
larynx they have produced fatal asphyxia. It 
is not very rare for them to enter the common 
bile duct and produce jaundice. They may even enter in great numbers 
the smaller bile ducts and produce hepatic abscesses. They have been found 
in the pancreatic duct, in the vermiform appendix, and in the splenic 
vein. It has long been known that they would perforate an intestine 
which was the seat of ulceration, but well authenticated cases have been 
reported in which they have perforated an intestine previously healthy, 
setting up a fatal peritonitis. In Archambault's case they perforated the 
stomach. In cases of a persistent Meckel's diverticulum, worms have 
been discharged from an umbilical fistula. They have been found in 
umbilical abscesses. Considering, however, the frequency of round- 
worms, migrations are rare. 

Symptoms. — The symptoms of roundworms are of the most in- 
definite kind; often there are none until the worm is discovered in the 
stools. It is then fair to assume that other worms are also present. The 
most frequent abdominal symptoms are colic, tympanites, and other 
symptoms of indigestion, loss of appetite, restless, disturbed sleep, grind- 




Fig. 67. — Ascaris Lumbri- 
coides. a, entire worm; 
b, head; c, eggs. (Jaksch.) 



INTESTINAL WORMS. 423 

ing of the teeth at night, and picking the nose. These symptoms are 
much more frequently due to other causes than to worms, but when all 
are present the existence of worms should be suspected. 

A great variety of nervous symptoms may be associated with intes- 
tinal worms. They are more often seen with lumbricoids than with 
either of the other varieties. The symptoms may be of the most puzzling 
character, and may simulate very closely those of serious organic dis- 
ease. There may be prolonged low fever, chills, headache, vertigo, hal- 
lucinations, hysterical seizures, epileptiform attacks, convulsions, tetany, 
transient paralyses such as strabismus, and even hemiplegia and aphasia. 
All these have been observed in connection with intestinal worms, and 
from the fact that the symptoms disappeared completely after the worms 
were expelled there seems to be but little doubt that they were the cause 
of the symptoms. As in the case of the abdominal symptoms, however, 
intestinal worms are only one of the causes of such nervous disturbances, 
and certainly not the most frequent; but the possibility that nervous 
disturbances may depend upon worms should not be overlooked. The 
blood generally shows eosinophilia, as in patients with tapeworm. 

The only positive evidence of the existence of roundworms is the dis- 
charge of a worm from the body, or the discovery of the ova in the stools. 
A microscopic examination of the stools is a valuable means of diagnosis, 
and one that is too infrequently employed. When worms are present the 
ova may be found in great numbers. Their continued presence, after the 
discharge of one worm, indicates that other worms remain. 

Treatment. — Altogether the most efficient agent for the removal of 
the worms is santonin. The same plan of administration may be fol- 
lowed as in the case of the tapeworm, viz., to give the drug on an empty 
stomach, preceded by a laxative. Santonin is best given in powdered 
form mixed with sugar. For a child of five years as much as three grains 
are usually required. This amount should be given in three doses at 
intervals of four hours, soon followed by a purge of calomel or castor oil. 
Or one or two grains of santonin may be given with half the amount 
of calomel every other night for three or four nights. The great dif- 
ficulty with santonin is its tendency to provoke vomiting. Occasionally 
in susceptible children, even with ordinary doses, toxic symptoms may 
develop, such as }^ellow vision, dark red or yellow urine, and nervous 
excitement or delirium. 

Oxyuris Vermicularis — Pinworm — Threadworm. — The oxyuris 
(Fig. 68) resembles a short piece of white thread. The female is 
about one-third of an inch long, the male about one-half that length, 
but is less frequently seen. The worm tapers toward the tail. The ova 
are of slightly irregular size, and are considerably smaller than those of 
the roundworm. 

The oxyuris inhabits the rectum, the caecum, and, according to- Still, 



424 



DISEASES OF THE DIGESTIVE SYSTEM. 




i 




\er\ Frequently the appendix. These worms may be found also in the 
lower small intestine, in the stomach, and even in the mouth. If present 
in the rectum they are usually discovered by separating the folds of the 
anus. The number of worms is usually large. The irritation to which 

they give rise causes a great pro- 
duction of mucus, and frequently 
leads to a chronic catarrh of the 
colon of considerable severity. The 
worms are imbedded in the mu- 
cus ; often they form with it small 
balls. According to Leuckart, they 
are incapable of multiplying in 

• H? HI ^ ^ s ^ u ' Doubt nas recently been 

/3l Iff if? ffl c thrown upon this view by the ob- 

Wl) ml ml J servations of Still. From the im- 

mature character and the large 
numbers of the worms found in 
the appendix (111 in one case), 
this writer believes that the ap- 
pendix may be a breeding place. 
The ova as well as the worms are 
passed in enormous numbers with 
the stools. They attach themselves 
to the folds of the skin, the hairs about the anus, and even to the genitals. 
The patient may, through lack of cleanliness of the parts, continually 
re-infect himself. After discharge from the body, the ova may be 
carried by flies and deposited upon fruits, vegetables, or in drinking 
water. 

Symptoms. — The principal local symptom caused by the oxyuris is 
itching of the anus or the genitals. This is caused by the migration of 
the worms from the bowel, and usually comes on at about the same hour 
at night, generally soon after the patient has retired. It is sometimes so 
intense as to be almost intolerable. It leads to frequent micturition, to 
incontinence of urine, in the male to balanitis, and in the female to 
vaginitis or vulvitis, and in both, but especially in the latter, it may be 
the cause of masturbation. Owing to the catarrhal colitis which is ex- 
cited, there is discharged from time to time a large quantity of mucus. 
Severe colicky pains are often associated. The irritation may lead to 
prolapsus ani. Nervous symptoms are not so frequently associated 
as with the other varieties of worms, although I have seen at least 
one case of chorea in which they were almost certainly the cause. They 
have been known to excite convulsions. The general health is some- 
times undermined and there may be marked and progressive loss in 
weight. 



Fig. 68. — Pinworms. a, head; b, female; c 
male; e, female and male, natural size 
d, ova. (Jaksch.) 



INTESTINAL WORMS. 425 

Treatment. — This is usually spoken of as a very simple matter, and 
no doubt in recent cases, or where the number of worms is small, this is 
true; but where the number is large, and considerable catarrhal inflam- 
mation of the colon is present, it is often a matter of the greatest dif- 
ficulty to rid the bowel of these parasites. Cases frequently resist treat- 
ment by injection for months, even though thoroughly used. The reason 
for this is, that only the lower colon is reached by injections while the 
worms may be chiefly in the caecum and even in the appendix and small 
intestine. While, therefore, injections are important and indeed invalu- 
able, they can not be relied upon exclusively. The most scrupulous atten- 
tion to cleanliness is an absolute necessity as the first step in the treatment 
of all cases. It is well to bathe the parts about the anus after each stool, 
and even two or three times a day, with a bichloride solution, 1 to 10,000. 
Itching is best controlled by the application of mercurial ointment to the 
folds of the anus at bedtime, this effectually preventing the escape of the 
worms from the bowel. The local application of cold will sometimes 
have the same effect. The most efficient of the injections is probably 
the bichloride. The colon should first be thoroughly cleansed by an 
injection of lukewarm water containing one teaspoonful of borax to the 
pint, in order to remove the mucus. When this has been discharged, half 
a pint of the bichloride solution of the strength mentioned should be 
injected high into the bowel through a catheter, and retained as long 
as possible. This should be repeated every second or third night. On 
other nights a simple saline injection may be employed. The infusion of 
quassia, asafoetida, aloes, and garlic are also useful. Solutions of car- 
bolic acid should never be employed. 

When the worms are high in the colon, drugs by the mouth must 
be combined with injections. Probably the most efficient remedy is 
santonin, which may be used as for roundworms. The expulsion of the 
worms is aided by saline cathartics; simple bitters, such as gentian and 
quassia, are also of some value. I have known one case, which resisted 
for over two years everything which had been tried, to be cured in 
two or three weeks by injections of a decoction of garlic, in connection 
with which garlic was given in liberal quantities by the mouth. 

Uncinaria Americaxa or Hookworm. — This belongs to the class 
of nematodes. The males are one-fourth to one-half inch in length and 
the females slightly longer. The parasite resembles the ankylostomum 
duodenale of Europe. Infection usually takes place through the skin 
of the bare feet, more rarely that of the hands. It is possible, however, 
to contract the disease by. eating dirty fruit or vegetables contaminated 
by the developing larvae; but infection does not occur from swallowing 
the ova or young larvae. After entering the skin the larvae find their way 
into the circulation and thus reach the lungs. From the lungs they may 
migrate or be coughed up into the mouth and then swallowed. They 



426 DISEASES OF THE DIGESTIVE SYSTEM. 

are not acted upon by the gastro-intestinal secretions, and in the upper 
part of the small intestine they develop into mature worms. These may 
exist in the small intestine for years. 

The symptoms in the milder cases are minor digestive disturbances, 
general malnutrition with moderate anaemia and arrested growth. In 
the more severe cases the anaemia is very marked, the haemoglobin often 
falling to thirty per cent or below. The leucocytes are normal in num- 
ber or slightly increased ; but the percentage of eosinophiles is above the 
normal. Usually the proportion reaches five or ten per cent; it may 
however be twenty-five per cent or even higher. (Edema of the face is 
common and there may be general dropsy without albuminuria. Af- 
fected children besides being very backward in physical development, are 
dull, inattentive and entirely wanting in physical or mental energy. 
The appetite is sometimes absent; but more characteristic is the crav- 
ing, not only for every kind of food, but for such articles as clay, dirt, 
chalk, etc. Death may be due to a progressive failure of nutrition or to 
intercurrent disease. 

Prophylaxis in the individual consists chiefly in the protection of the 
feet of persons living in an infected district, by wearing shoes. The 
chief remedy for the hookworm is thymol. Its administration should be 
preceded by one or more full doses of the sulphate of magnesia or soda 
given upon a fasting stomach. The quantity of thymol given to a child 
of five years should be six or eight grains in divided doses in the course 
of three or four hours. It may be administered either in capsule or in 
suspension. Two hours after the last dose, the salts should be repeated; 
but no food should be given until the cathartic has acted freely. Castor 
oil should not be used. A repetition of the treatment is often necessary 
before a cure is accomplished. 



CHAPTER X. 

DISEASES OF THE RECTUM. 

PROLAPSUS ANI. 

Under this term are included two conditions. In the first, or partial 
prolapse, there is simply an eversion of the mucous membrane which 
protrudes beyond the sphincter. In the second, or complete prolapse, 
there is invagination of the rectal wall for a variable distance, usually 
two or three inches. 

Etiology. — Prolapse is most common in children during the sec- 
ond and third years. Its frequency in early life is partly due to the lack 
of support furnished by the levator-ani muscles. It also occurs very 



PROLAPSUS ANI. 



427 



readily when the ischio-rectal fat is scanty; it is therefore often seen in 
children suffering from marasmus. The exciting cause may be anything 
which provokes severe and prolonged straining. This may be either the 
tenesmus accompanying inflammation of the rectal mucous membrane 
or chronic constipation. It may come from phimosis or stricture of the 
urethra, and it is a very frequent symptom of stone in the bladder. 

Symptoms. — Prolapse usually occurs during the act of defecation. It 
is generally easily reduced, but shows a great disposition to return with 
every stool. In obstinate cases the bowel comes down at other times. 
The appearance of the tumour varies with its size. In the slighter form 
there is simply a ring composed of a fold of mucous membrane sur- 
rounding the anus. In the more severe form there is a flattened, corru- 
gated tumour, usually about the size of a small tomato (Fig. 69). The 




Fig. 69. — Prolapsus Ani. 



mucous membrane covering the tumour is of a deep purplish-red colour, 
and bleeds readily. It may be the seat of catarrhal or membranous in- 
flammation. The diagnosis in most cases is easy, although the tumour 
has been confounded with polypus and intussusception. 

Treatment. — In most cases reduction is easily accomplished by laying 
the child upon its face across the lap, and making gentle pressure upon 
the tumour with oiled fingers. The application of cold, either by means 
of ice or cold cloths, is of assistance in cases which are not at once re- 
duced by pressure. After reduction, in the milder cases the child should 
be kept upon its back for at least an hour. When the tumour tends to 
come down with every stool, special attention should be given at this 
time. If an infant, the bowels should always move while the child lies 
upon his back, and during defecation the buttocks should be pressed to- 
gether by a nurse. Older children should use an inclined seat placed at 



428 DISEASES OF THE DIGESTIVE SYSTEM. 

an angle of about forty-five degrees, but should never sit upon a low 
chair or assume any position in which straining is easy. After defecation 
the patient should lie down for at least half an hour. Where there is 
constipation, the bowels should be kept free by means of laxatives. If 
there is a diarrhoea, tenesmus may be overcome by frequent sponging 
with ice water, or by the use of small injections of ice water and tannic 
acid, in the proportion of twenty grains to the ounce. In more severe 
cases it may be controlled by the use of suppositories of opium. When 
the bowel tends to come down frequently, this may be prevented by the 
use of an adhesive strap two or three inches wide, placed tightly across 
the buttocks. This is better in the milder cases than a T-bandage. The 
great majority of the cases are cured by these means in the course of a 
few weeks. 

In the most severe cases the bowel not only protrudes during defeca- 
tion, but also in the interval, and it may be down for days at a time. 
Such cases are rarely seen except in infants who have very flabby muscles, 
and but little adipose tissue at the floor of the pelvis. Eeduction is 
sometimes difficult in cases when the prolapse has lasted a long time. It 
is often facilitated by painting the protruding part with a two-per-cent 
solution of cocaine, and then dilating the sphincter by passing the finger 
into the central opening of the tumour. After reduction, suppositories 
containing from one-fourth to one grain of cocaine may be inserted. 
They are more efficient than those containing opium or belladonna. A 
firm pad should be applied over the anus, held in position by a T-bandage. 
For several days at a time a short rubber tube may be kept in the rec- 
tum, held in place by adhesive plaster. The bowels should be kept freely 
open. Where all other measures fail, the protruding part may be 
touched with the Paquelin cautery, linear markings being made at in- 
tervals of an inch. Amputation or excision is not required in children. 



FISSURE OF THE ANUS. 

This is not a very uncommon condition in children. The most fre- 
quent cause is the passage of a large, hard, faecal mass. Sometimes it 
results from traumatism inflicted with the nozzle of a syringe while 
giving an enema. It may be produced by the scratching excited by pin- 
worms. In the beginning there is a simple tear at the margin of the 
anus. The laceration which is produced usually heals promptly; but if 
the cause is repeated, healing is prevented, and there is finally produced 
a linear ulcer, or a true fissure, which may last for some time and be a 
source of great annoyance. 

A fresh fissure has the appearance of any other tear at a muco-cuta- 
neous orifice. One of longer standing has a gray base, slightly indurated 
edges, often discharges a small amount of pus, and bleeds a drop or two 



PROCTITIS. 429 

with nearly every movement of the bowels. The most constant symptom 
is pain, whch usually occurs with the act of defecation, and continues for 
some time afterward. It is most severe when the fissure is just at the 
margin of the sphincter, and leads the child to resist every inclination to 
have the bowels move, so that it becomes a cause of chronic constipation, 
which condition again greatly aggravates the fissure. The pain is often 
referred to other parts in the neighbourhood. 

The treatment is simple and usually efficient. It consists in clean- 
liness, overcoming the constipation, and touching the fissure with nitrate 
of silver, preferably with the solid stick. If the case is not speedily re- 
lieved by such measures, the sphincter should be stretched as in adult 
patients. 

PROCTITIS. 

Proctitis, or inflammation of the rectum, usually occurs with inflam- 
mation of the rest of the large intestine, but it may occur alone. It is 
to the cases in which only the rectum is involved that the term is gen- 
erally applied. 

The causes are for the most part local. A frequent one in infants 
is the use of irritating injections or suppositories, either for the relief of 
constipation or as a means of administering certain drugs. I have seen 
one obstinate case in an infant a year old, following the prolonged use of 
glycerin suppositories. It is sometimes caused by traumatism, especially 
by the careless giving of an enema. It accompanies pinworms. In 
certain cases it may result from direct infection through the anus. This 
may be from a gonococcus inflammation extending from the vagina or 
urethra, or from an infection due to other bacteria, particularly in cases 
of measles, scarlet fever, and diphtheria; or, finally, it may be due to 
syphilis. The varieties of inflammation are the same as in the rest of the 
intestine. Proctitis may thus be catarrhal, membranous, or ulcerative. 

Catarrhal Proctitis. — The pathological conditions are the same as in 
ordinary catarrhal inflammation of the intestinal mucous membrane. By 
the introduction of a speculum, or by simply everting the mucous mem- 
brane, it is seen to be reddened, swollen, and bleeds easily. There is a 
copious secretion of mucus. In cases of long standing there may be 
superficial ulceration appearing as a white or yellowish-white surface, 
usually just inside the sphincter. 

The symptoms are chiefly local, although a condition of general irrita- 
bility may result from the local condition. There is heightened reflex 
action, so that the stool often comes with a squirt. There is pain with 
defecation, and mucus is discharged, usually as a clear, jelly-like mass, 
and sometimes in the form of a cast, but not generally mixed with the 
stool. There are usually traces of blood, sometimes quite large haemor- 
rhages. In the most acute cases, tenesmus is present both during and 



430 DISEASES OF THE DIGESTIVE SYSTEM. 

after the stool. There may be prolapsus ani. The skin in the vicinity is 
irritated by the discharges, most frequently so in infants. If the cause 
is pinworms, there may be intense itching. The duration of the disease 
is indefinite, depending upon the cause. It may be a few days or many 
months. The inflammation may extend from the rectum to neighbouring 
parts, leading to ischio-rectal abscess. 

Membranous Proctitis. — It has been customary to describe this as a 
complication of diphtheria, usually occurring with diphtheria of the ex- 
ternal genitals. As very few of these cases have been studied bacteriolog- 
ically, it is impossible to say what proportion of them, if any, are to be 
regarded as true diphtheria. It is probable that the great majority are 
due to infection by streptococci. When the infection is from the intes- 
tine above, the rectum is never affected alone. When it is from below, 
this may be the case. The lesions are the same as in membranous in- 
flammation occurring higher in the colon. The symptoms resemble those 
of the catarrhal variety, with the addition that the stools contain pieces 
of pseudo-membrane. This can be made out only by repeatedly washing 
the discharges with water. If accompanied by prolapse, the pseudo- 
membrane may be seen. Membranous proctitis may be complicated by 
a membranous inflammation of the genitals or the perinaeum. Although 
it is usually acute, it may last for weeks. 

Ulcerative Proctitis. — Ulcers of the rectum may be the result of a 
catarrhal inflammation; these, however, are usually superficial, affecting 
the mucous membrane only, and in most cases heal rapidly. Sometimes 
they extend more deeply into the submucous or even the muscular coat. 
They are then chronic, often very obstinate, and may last indefinitely. 
Follicular ulcers of the rectum are nearly always associated with the 
same condition in the sigmoid flexure. These are always multiple and 
usually small, rarely being more than a quarter of an inch in diameter. 
Sometimes the small ones coalesce, producing much larger ulcers. Mem- 
branous proctitis is rarely followed by ulceration, although this is a 
possible result where sloughing has occurred. Single ulcers may be of 
tuberculous origin. Steffen reports two cases of tuberculous ulcer of the 
rectum in children of seven months and three years respectively. I have, 
in a young infant, seen one such ulcer, which was fully three-fourths of 
an inch in diameter, and was not associated with other tuberculous dis- 
ease of the large intestine. Syphilitic ulcers are extremely rare in 
children. 

The symptoms of ulcer of the rectum are mainly two — pain and haem- 
orrhage. The pain is of variable intensity, and may be referred to the 
coccyx, or to any of the neighbouring parts. The amount of bleeding 
may be small, the blood coming in clots, or it may be fluid and in so 
large a quantity as to produce general symptoms. It usually accom- 
panies every stool. In addition the stool contains more or less pus, par- 



ISCHIORECTAL ABSCESS. 431 

ticularly in chronic cases. When the ulcer is low down, tenesmus is 
present and may be a prominent symptom. A positive diagnosis of ulcer 
can be made only by examination with a speculum. 

Treatment. — In cases of acute catarrhal proctitis injections of some 
bland fluid should be employed, such as a starch-water, limewater, a mix- 
ture of oil and limewater, or a warm one-per-cent saline solution. The 
local cause, if one exists, should be removed. The disordered diges- 
tion, when present, is to be treated according to its special symptoms. 
In the most acute cases the patient should be kept in bed. When the 
tenesmus is severe, suppositories of opium may be used. In the more 
chronic cases saline injections should be given, and followed by a mild 
astringent like tannic acid, ten grains to the ounce, or a one-per-cent 
solution of hamamelis. Cases associated with pinworms are especially 
obstinate. Here the treatment is first to be directed to the worms, and 
afterward to the proctitis. 

In the membranous cases the same measures are to be employed, and 
in addition the injection of a warm boric-acid solution two or three 
times a day. 

Cases of ulcer require the most careful treatment. In many there is 
but little tendency to spontaneous recovery. An examination with the 
speculum should be insisted upon in all cases of chronic proctitis, to 
make sure of the diagnosis. Rest in bed is essential to a rapid improve- 
ment. The patient should be put upon a bland diet, especially of milk, 
and the bowels kept freely open by the use of laxatives, and injections 
twice a day of a saturated boric-acid solution. Locally there should be 
applied a solution of nitrate of silver, one grain to the ounce, the bowel 
having previously been washed with tepid water. If a stronger solution 
than this is used, it should be neutralised after half a minute by the 
injection of a salt solution. 



ISCHIO-RECTAL ABSCESS. 

This is not a very rare condition even in infancy. Infection from the 
rectum, usually through the lymph channels, seems to be the most com- 
mon cause, although sometimes the abscess may be traced directly to trau- 
matism. In a single year I have seen six such cases. All but two were 
small, circumscribed abscesses, and quite superficial, apparently starting 
as an acute inflammation of the lymph glands of the region. They are 
analogous to a similar process in the lymph glands of the neck, seen in 
infancy. These cases healed promptly after incision. In other instances 
there is seen a disposition to burrow, as in adults. Only once have I met 
with diffuse suppuration in the ischio-rectal region, terminating in 
sloughing and death, and this was in an infant only three months old. 

Essentially the same varieties of inflammation are seen in early life as 



432 DISEASES OF THE DIGESTIVE SYSTEM. 

in adults. Mdsl of these cases recover promptly after simple incision 
and cleanliness, fistula being a rare sequel. 

RECTAL POLYPUS. 

Polypi are rarely seen in children, but, when present, may be the 
cause of rather obscure symptoms. The most important one is haemor- 
rhage. This at first occurs at intervals of days or weeks. The amount 
of blood lost is from a drachm to an ounce or more. Later, the haemor- 
rhages become more frequent and may be almost continuous, although 
rarely profuse enough to produce serious symptoms. The diagnosis of 
polypus is made only after a local examination. Sometimes the tumours, 
are within the reach of the finger; in other cases a proctoscope must be 
employed. Spontaneous cure often takes place by the sloughing of the 
tumour, after which the bleeding soon ceases. In other cases operation 
is necessary. 

HEMORRHOIDS. 

These, fortunately, are not often seen in children, although they occur 
in those as young as three or four years, and in some cases may even be 
congenital. The principal cause is chronic constipation, rarely diarrhoea. 
The tumours are generally small and external, the chief symptom com- 
plained of being pain on defecation. Bleeding sometimes accompanies 
the pain, but the haemorrhages are usually small. The treatment is to be 
directed toward the underlying cause. In most of the cases this suffices 
to cure the condition. I have rarely seen in a young child a case requir- 
ing operation, although neglect may make this procedure necessary. 

INCONTINENCE OF FECES. 

Inability to control the faecal evacuations is seen in certain cases of 
paraplegia due to myelitis, in injury of the lumbar portion of the spinal 
cord, and in spina bifida. It is also seen in acute disease, as in the coma 
of meningitis, and occasionally in the typhoid condition and in extreme 
adynamia, from any cause. It is quite common in severe attacks of 
chorea. In all these conditions incontinence of faeces is a symptom giv- 
ing rise to much annoyance and needing careful attention. Uncleanli- 
ness with reference to excreta, seen in idiocy, can hardly be classed as 
incontinence. 

Besides these familiar forms, the condition is sometimes seen from 
causes somewhat resembling those of incontinence of urine. The tone 
of the sphincter becomes so feeble that it does not resist even the slight- 
est impulse to evacuate the rectum. The discharge may take place with 
but little warning, and may occur either by day or night. In some cases 
a local cause exists, such as stretching of the sphincter by an old rectal 



DISEASES OF THE LIVER. 



433 



prolapse. It lias followed overdistention. of the rectum from prolonged 
chronic constipation. Ostheimer reports a case in which a vesical cal- 
culus was present. It is sometimes seen after severe acute illness, as a 
result of a loss of general muscular tone. In certain children it has been 
known to persist from infancy until the age of ten or twelve years. It 
may come on as a somewhat acute condition in highly nervous patients 
with poor general nutrition. The causes are chiefly of local and nervous 
origin. The treatment is rather unsatisfactory, except in recent cases 
and in those due to local causes which can be removed. If constipation 
exists the rectum should be emptied daily, preferably by an enema. 
The remedies which have proven most successful are strychnia, ergot, 
and belladonna, but they must be given in full doses, sometimes advan- 
tageously by suppository as well as by mouth. The general health should 
receive careful attention. 



CHAPTER XI. 



DISEASES OF THE LIVER. 



Aside from the different forms of degeneration which are seen in the 
various infectious diseases, the liver is not often the seat of serious dis- 
ease in infancy and early childhood. In later childhood nearly all the 
forms seen in adult life are occasionally met with, although even then 
they are quite rare. 

Size and Position. — The weight of the liver in the newly-born child, 
from one hundred and seven observations of Birch-Hirschfeld, is 4.5 
ounces (127 grammes), or about 4.2 per cent of the body weight. The 
following table gives the results of one hundred and seventy-four ob- 
servations upon the liver in infancy in the autopsy room of the New 
York Infant Asylum: 





Average. 


Per cent of 




Ounces. 


Grammes. 


body weight. 


3 months 


6.3 

7.5 

11.0 

14.0 

16.0 


180 
212 
311 
397 
453 


3.1 


6 " 


3.0 


12 " , 


3.40 


2 years 

3 " 


3.37 
3.26 







In adults, according to Frerichs, the weight of the liver is about 2 . 5 
per cent of the weight of the body. 

The upper border of the liver is best made out by percussion. In the 
child, the upper limit of the liver dulness in the mammary line is found 
29 



434 DISEASES OF THE DIGESTIVE SYSTEM. 

in the fifth intercostal space; in the axillary line, in the seventh space; 
posteriorly, in the ninth space. The lower border is best determined by 
palpation. This, as a rule, in the mammary line is found about one-half 
an inch below the free border of the ribs. According to Steffen, the left 
lobe is relatively larger in the child than in the adult. The liver may be 
displaced downward by contraction of the chest, as in rickets, or by an 
accumulation of fluid in the pleural cavity. It is frequently found lower 
than normal in conditions of great emaciation, owing to relaxation of the 
abdominal walls and its ligamentous supports. Upward displacement is 
much less frequent, and depends usually upon ascites or abdominal 
tumours. 

Malformations and Malpositions. — Congenital malformations relate 
chiefly to the bile ducts. These have been considered in the chapter de- 
voted to Icterus in the Newly Born. 

The liver may be found upon the left side in cases of general trans- 
position of the viscera. In diaphragmatic hernia it has been found in 
the thoracic cavity. 



CHRONIC FAMILY JAUNDICE. 

This disease is usually hereditary, but it occasionally exists in sev- 
eral brothers and sisters, the parents being unaffected. Similar cases may 
be seen without a family association. There are records of many fami- 
lies in which jaundice has existed through three or four generations. 
It is transmitted alike through the male and female descendants, and not 
all of the children in a family are affected. The descendants of unaf- 
fected members escape. The jaundice may be noticed shortly after 
birth, or it may develop at any time during childhood, sometimes not 
until later. This is the most striking feature of the disease. The dis- 
colouration may be very slight and noticeable only in the sclerotics, or 
the skin may be icteric. The colour is never very intense. It varies 
somewhat in degree and is increased after intercurrent gastro-intestinal 
attacks, which are rather frequent. When once developed, the icterus 
never entirely disappears. 

This jaundice is not obstructive; the stools are usually darker than 
normal and the urine contains urobilin in excess, but no bile. There 
is an increased production of biliary pigment, The liver is normal or 
slightly enlarged. The spleen is regularly, and often excessively, en- 
larged, and even in youth there may be attacks of biliary colic and of 
perisplenitis. Anaemia of a moderate grade is the rule. Both the red 
cells and haemoglobin are reduced, and a few nucleated red cells may be 
found. Very characteristic of the disease is the increased fragility of 
the red cells to haemolytic agents, especially to hypotonic salt solutions. 

The growth and development of children go on uninfluenced by the 



CATARRHAL JAUNDICE. 435 

condition, and many affected persons have lived to an advanced age. 
There are no characteristic post-mortem findings, and the disease is un- 
influenced by treatment, 1 

CATARRHAL JAUNDICE. 

This is due to a catarrhal inflammation of the common bile duct 
with which there is usually associated a similar inflammation of the 
duodenum and sometimes of the stomach also. The term gastro- 
duodenitis is sometimes used synonymously with catarrhal jaundice. 
The jaundice in these cases is due to obstruction which is caused by 
swelling of the mucous membrane of the bile duct. Catarrhal jaundice 
is rare in infancy. I have never seen it in a child under two years old. 
In children from three to six years it is not uncommon, and curiously 
occurs much more frequently in the fall months. This suggests an 
infectious origin. For the most part its causes are obscure. 

It occasionally complicates malarial fever. I have seen it several 
times with influenza, and it may occur with any of the infectious dis- 
eases. Rehn has described a form which occurred epidemically. 

The symptoms of the disease are quite uniform. When primary, the 
onset is like an ordinary attack of indigestion, with vomiting, pain, 
slight fever, and a moderate amount of prostration. The vomiting in 
some of the cases is repeated for several days. The pain may be quite 
severe, and localised in the region of the duodenum. It may be asso- 
ciated with tenderness in this region. The bowels are usually consti- 
pated. After three or four days, icterus, which is the only diagnostic 
symptom, appears. It is first seen in the conjunctiva, afterward in the 
skin, varying in degree according to the severity of the attack, but in 
most cases not being very intense. It is accompanied by the regular 
symptoms of obstructive jaundice. The stools are gray, sometimes white; 
there is a marked amount of intestinal flatulence. The urine is very 
dark, of a yellowish-green or bronze hue, and stains the clothing. There 
is complete anorexia; the tongue is thickly coated with a white fur. 
Headache, dulness, and languor are present, and the patient feels gen- 
erally wretched. The slow pulse and the itching skin are uncommon 
symptoms in children. The liver is usually found, upon examination, 
slightly enlarged, and sometimes tender on pressure. The duration of 
the disease is about two weeks, the general symptoms disappearing be- 
fore the icterus. Recurrences and prolonged attacks are occasionally seen. 

The diagnosis rarely presents any difficulty, and the prognosis is 
invariably good. 

Treatment. — In the diet, fats and starches should be reduced to a 
low point or be entirely prohibited. Patients usually do much better 

1 Tileston and Griffin, American Journal of the Medical Sciences, June, 1910. 



436. DISEASES OF THE DIGESTIVE SYSTEM. 

upon a diet of rare meat, fruit, and of skimmed milk, or buttermilk. If 
there is very much vomiting, the milk should be largely diluted with 
lime-water. The amount of food given should be small, but water should 
be allowed freely, particularly the mineral waters. The bowels should be 
opened every other day by calomel, followed by a saline purgative. In 
most of the cases no other treatment is necessary. When the pain is 
severe it may be relieved by counter-irritation by mustard, turpentine, 
or even cantharides. The gastric symptoms should be managed as are 
those of ordinary acute gastritis. The restricted diet should in all cases 
be continued for at least a week after the jaundice has disappeared. 



FUNCTIONAL DISORDERS OF THE LIVER. 

Functional disorders of the liver are undoubtedly exceedingly com- 
mon in childhood. They are as yet but little understood, and it is 
almost impossible to separate them from the other symptoms of intes- 
tinal indigestion with which they are associated. These are described in 
the chapter upon Chronic Intestinal Indigestion. Some of these symp- 
toms depend upon a diminution in the quantity, or the impoverished 
quality of the biliary secretion. There are gray or white stools, flatu- 
lence, and other evidences of increased intestinal putrefaction. These 
probably depend upon imperfect absorption in consequence of the ab- 
sence of bile. The other functional disorders of the liver relate to 
its effect upon the transformation of nitrogenous substances. The 
nature of this change, and the symptoms which result from this dis- 
turbance are as yet but imperfectly understood. It is quite probable that 
many of the nervous functional disorders of children — for example, 
attacks of migraine or of cyclic vomiting — may. depend upon such a cause. 

NEW GROWTHS. 

New growths of the liver are rare in children and are usually sec- 
ondary to deposits elsewhere, most frequently in the kidney. They are 
generally sarcomatous. Primary sarcoma of the liver has, however, been 
observed, and at so early an age as to make it practically certain that 
the condition was a congenital one. A single example of primary adeno- 
sarcoma of the liver has fallen under my observation. This was in an 
infant only seven months old. In a report of this case I collected from the 
literature ten cases of sarcoma of various types in infants under one 
year. 1 In most of the cases there is simply a slowly increasing abdominal 
tumour and progressive asthenia. 

1 Archives of Paediatrics, April, 1905. 



ABSCESS OF THE LIVER— SUPPURATIVE HEPATITIS. 437 

ACUTE YELLOW ATROPHY. 

This form of hepatic disease is very rare in children. Greves has 
reported a well-marked case in an infant of twenty months, and has 
collected seventeen other cases under ten years of age ; the youngest was 
in an infant three months old. The symptoms and course of the disease 
are essentially the same as in adults. A condition closely allied to this 
is occasionally seen as a result of the administration of chloroform. 

CONGESTION OF THE LIVER. 

Congestion of the liver occurs from the same causes in children as 
in adults. Acute congestion is not often seen. Chronic congestion is 
more common, and is usually secondary to general venous obstruction de- 
pendent upon congenital or acquired heart disease, atelectasis, or other 
pulmonary conditions, particularly chronic pleurisy, chronic interstitial 
pneumonia, and emphysema. Chronic congestion of the liver causes no 
characteristic symptoms except a moderate enlargement of the organ 
with some pain and tenderness. The treatment is that of the primary 
disease. 

ABSCESS OF THE LIVER— SUPPURATIVE HEPATITIS. 

In 1890 Musser found but thirty-four recorded cases of abscess of 
the liver in children under thirteen years. Since that time a few addi- 
tional cases have been reported. In the above collection, there have 
not been included cases of suppurative hepatitis occurring in the newly 
born. 

As in adults, abscess of the liver may result from traumatism, or it 
may be secondary to suppurative pylephlebitis, which depends upon a 
focus of infection in the umbilical vein, or in some part of the abdomen 
from which the branches of the portal vein arise. Pylephlebitis may fol- 
low appendicitis (Bernard's case), it may follow typhoid fever directly 
(Asch's case), or be due to suppuration of the mesenteric glands or peri- 
tonitis following typhoid. In seven of the cases collected by Musser the 
disease was due to migration of roundworms from the intestine into 
the hepatic ducts. Menger (Texas) has reported one case following 
dysentery, the only one, I think, on record in this country. Very rarely 
great numbers of minute abscesses are found as a result of suppurative 
thrombosis of the jugular bulb following middle ear disease. In quite 
a number of cases no adequate cause can be found. 

In the cases occurring in pyaemia and in those associated with pyle- 
phlebitis there are usually several abscesses ; in traumatic cases generally 
but one. If untreated, the majority of cases prove fatal either from ex- 
haustion or from rupture into the pleura or peritonaeum. In Asch's 
case spontaneous cure took place by rupture into the intestine. 



4;}$ DISEASES OF THE DIGESTIVE SYSTEM. 

Symptoms.— Occasionally abscess of the liver is latent, but in most 
of the rases the symptoms are marked and sufficiently characteristic to 
make the diagnosis a matter of no great difficulty. The most constant 
general symptoms are chills, which may be single, but are usually re- 
peated; fever, which is commonly of the hectic variety and followed by 
sweating; prostration, vomiting, diarrhoea, and cachexia. Jaundice is 
present in less than half the cases, and is rarely intense. The liver is 
almost invariably sufficiently enlarged to be easily made out by palpation 
or by percussion ; the enlargement in most cases is chiefly downward. 
Pain is quite constant, and frequently intense, but not always in the 
region of the liver. It may be in the epigastrium, at the umbilicus, in 
the lower part of the abdomen, and occasionally in the right shoulder. 
Tenderness over the liver is usually present. A positive diagnosis of 
hepatic abscess is to be made only by aspiration and the withdrawal of 
a fluid having the characteristics of " liver pus." Pulmonary symptoms 
usually exist with an abscess occupying the convexity of the right lobe. 
There may be cough and dyspnoea from pressure, or pleurisy from ex- 
tension of the inflammation through the diaphragm, or from rupture 
into the pleural cavity. The usual duration of abscess of the liver after 
the beginning of the symptoms is from one to two months. The prog- 
nosis will depend upon the cause of the disease. The pysemic cases are 
usually fatal. In Musser's collection, the proportion of recoveries was 
about thirty per cent. At the present time, with improved methods of 
treatment and earlier diagnosis, the outlook is somewhat better than this. 

Treatment. — This is purely surgical. Without operation the chances 
of recovery are very slight. A small number of cases have been cured 
by aspiration, but in the vast majority only incision and drainage are to 
be depended upon, and, if the abscess is accessible, should be resorted to 
as soon as the diagnosis is established. 



CIRRHOSIS. 

Cirrhosis of the liver is exceedingly rare in early life, although quite 
a number of cases are now on record between the ages of seven and four- 
teen years. Sixty-five have been collected by Howard and fifty-three by 
Laure and Honorat. Nearly all the cases in these collections were be- 
tween nine and fifteen years old. Cirrhosis in infancy is usually of 
syphilitic origin. Two-thirds of those in Howard's collection were males. 
The etiology in most of the cases is obscure; in over half of those re- 
ported no cause could be discovered. Fifteen per cent of Howard's 
cases were traced to alcoholism, eleven per cent to syphilis, and eleven 
per cent to tuberculosis. Laure and Honorat believe that the eruptive 
fevers sometimes play an important part as an etiological factor, and that 
at other times the cause is possibly malaria. 



AMYLOID DEGENERATION. 439 

The anatomical features of cirrhosis in early life arc essentially the 
same as in adults. The liver is sometimes enlarged, but usually it is 
smaller than normal. The connective tissue may be distributed around 
the lobules, along the bile ducts, in irregular patches, or in striations 
through the organ. Associated with this there is atrophy and fatty 
degeneration of the liver cells. In some of the* cases reported there has 
been also a similar increase in the connective tissue of the spleen and 
kidneys. 

Symptoms. — These are very much the same as in adult life. In the 
beginning there are the indefinite disturbances referable to the digestive 
organs, and the liver may be slightly enlarged; later there is ascites, 
enlargement of the spleen, and dilatation of the abdominal veins. Ascites 
is a pretty constant symptom, and is generally marked. Slight icterus 
is often present, but a marked amount is rare. There may be haemor- 
rhages from the stomach, from the nose, or from other organs ; in a few 
cases there is slight fever. The late symptoms are, a small liver, marked 
ascites with the consequent embarrassment of respiration, cachexia, and 
sometimes general dropsy. Diarrhoea is a much more constant symptom 
than in adults. Death usually takes place from exhaustion. The course 
of cirrhosis in children is commonly more rapid than in adults, and the 
progress is steadily downward. 

Treatment. — Medicinal treatment is of avail only in cases which are 
syphilitic. These should be put upon anti-syphilitic remedies in full 
doses. The treatment in other respects is symptomatic and palliative. 
As largely as possible patients should be kept upon a milk diet. The 
ascites may require paracentesis as in adults. 



AMYLOID DEGENERATION (Waxy or Lardaceous Liver). 

From the experiments of Krawkow, Davidsohn, and others there 
seems now little doubt that amyloid degeneration can be produced by the 
prolonged action of the staphylococcus aureus, and probably by other 
organisms. Amyloid degeneration of the liver is associated with similar 
changes in the spleen and kidneys, and sometimes in the villi of the small 
intestine, and is usually seen in children after long-continued suppura- 
tion in chronic bone or joint disease, empyema, tuberculosis, or syphilis. 

The liver is generally very much enlarged ; in extreme cases a weight 
of six or seven pounds may be reached. It is of a glistening, waxy ap- 
pearance, very firm and hard. With a solution of iodine, a mahoganv- 
brown reaction is obtained. The amyloid substance is deposited between 
the capillaries and the hepatic cells, leading to occlusion of the vessels 
and atrophy of the cells from pressure. 

Amyloid liver per se produces few symptoms. Ascites is rarely pres- 
ent except in cases in which the liver is very large, and jaundice does not 



440 DISEASES OF THE DIGESTIVE SYSTEM. 

occur. In addition to the symptoms of the original disease in the 
course of which the amyloid degeneration occurs, there is the peculiar 
waxv cachexia which is seen in no other condition, but resembles some- 
what that belonging to malignant disease. The face has the appearance 
of alabaster, and the skin has a singular translucency. The liver may be 
so large as to form a tumour, sometimes nearly filling the abdominal 
cavity. Not infrequently it extends to the umbilicus, and even to the 
crest of the ilium. The surface is smooth and hard, and the edges usually 
rounded. There is no localised pain or tenderness. The spleen is in- 
variably enlarged. As a result of the associated amyloid degeneration of 
the kidney, there may be anasarca and albuminuria. Dropsy may occur 
from pressure of the large liver upon the vena cava, apart from the con- 
dition of the kidney. 

Amyloid changes usually take place slowly, the whole course of the 
disease being marked by years, the patient dying from slow asthenia, 
from nephritis, or from some acute intercurrent disease. As a rule, cases 
go on steadily from bad to worse; but sometimes, after the disease has 
reached a certain point, the condition remains stationary for a long time. 

The prognosis is always bad, although in a few cases improvement, 
and even cure, are stated to have occurred after the excision of the dis- 
eased joints upon which the amyloid degeneration depended. When due 
to syphilis, the usual anti-syphilitic remedies should be given. 

FATTY LIVER. 

Fatty infiltration of the liver is generally a secondary condition in 
early life, and causes no symptoms by which it can be positively recog- 
nised. Considerable discussion has of late arisen regarding its frequency 
in infants. From our records at the Babies' Hospital, Dr. Martha Woll- 
stein has tabulated 345 consecutive autopsies in which the condition of 
the liver was carefully noted. The liver was fatty in 201, or 58 per cent. 
Of these autopsies, 63 were cases of tuberculosis, in 43 of which, or 68 
per cent, the liver was fatty. 

The general nutrition of the 345 infants was as follows : 

Wasted 188: liver fatty, 104, or 55 per cent— very fatty in 17. 

Fairly nourished 80: " " 52, "66 " " " " " 9. 

Well nourished 77: " " 45, "59 " " " " "20. 

These figures coincide very closely with the observations of Free- 
man at the Xew York Foundling Hospital, and indicate that fatty liver 
is not, as has been so often asserted, much more frequent in wasted 
infants than in others. The cause of this change in the liver is as yet 
but little understood. 

The liver is moderately enlarged, smooth, with rounded edges, of a 
yellowish-red or a lemon-} r ellow colour, and can be indented with the 



BILIARY CALCULI. 441 

finger. A warm knife becomes coated with oil after cutting. Microscop- 
ically there is seen an accumulation of fat in the liver cells, usually 
irregularly distributed, but chiefly in the periphery of the lobule. Jaun- 
dice, ascites, and the other peculiar symptoms of hepatic disease are 
absent. The liver is moderately increased in size and its functions may 
be interfered with, but not in such a way as to be recognised by the 
symptoms. The treatment is that of the original disease. 

HYDATIDS. 

Echinococcus disease of the liver, while rare among adults in this 
country, is almost unknown in children. I have been able to find but 
two recorded cases in America. From twenty-two European cases col- 
lected by Pontou, it appears that unilocular cysts are especially frequent 
in young subjects. If the upper surface is affected, pulmonary symp- 
toms, cough and dyspnoea, are usually present; if the under surface 
of the organ, there is pressure upon the portal vein, the vena cava, bile 
ducts, stomach, and intestines. This pressure may cause icterus, dilata- 
tion of the superficial abdominal veins, and sometimes ascites. The local 
signs are enlargement of the liver with a tumour, which is easily recog- 
nised in children because of the thin abdominal walls. The hydatid 
fremitus is usually obtained. By aspiration a clear fluid is withdrawn, 
showing under the microscope the presence of the hooklets, which estab- 
lishes the diagnosis. Occasionally cure may take place by spontaneous 
rupture or suppuration of the cyst, but in most cases, when left to itself, 
the disease proves fatal. The treatment is surgical, and consists in 
aspiration or in incision, and the evacuation of the cyst. 

BILIARY CALCULI. 

Up to the age of puberty calculi are extremely rare. Of twenty cases 
collected by Still, eleven occurred in newly-born infants or else gave 
symptoms during the first month of life. The prominent symptom was 
intense and persistent jaundice. Nearly all died within the first month, 
the autopsy usually showing multiple calculi in the common duct. 

The cases in older children do not differ from those in adults. 



CHAPTER XII. 
DISEASES OF THE PERITONEUM. 



Inflammation of the peritonaeum is not very frequent in childhood, 
because at this time most of the causes which are operative in later life 
either do not exist at all or are infrequent. 



442 DISEASES OF THE DIGESTIVE SYSTEM 

We shall consider separately acute, chronic, and tuberculous perito- 
nitis. 

ACUTE PERITONITIS. 

Acute peritonitis may occur at any period of infancy or childhood. 
It may even exist in intra-uterine life. In the newly born, peritonitis is 
not infrequent. After this time it is exceedingly rare during infancy, 
only four cases, including all varieties, being met with in 726 consecutive 
autopsies in the New York Infant Asylum. After the fifth year the 
disease is relatively much more common. Of the 187 cases above re- 
ferred to, 25 per cent occurred in the newly born, 21 per cent between 
one and five years, and 54 per cent between the fifth and the sixteenth 
years. 

Etiology. — In the newly born, peritonitis is seen as one of the most 
frequent lesions of acute pyogenic infection. It is usually due to direct 
infection through the umbilical vessels. In infancy and childhood, 
peritonitis occurs both as a primary and secondary inflammation. The 
primary form is rare. It may be due to traumatism, such as falls or 
blows, or to surgical operations upon the abdomen; it has occurred after 
an injection for the cure of a congenital hydrocele. In a very small 
number of cases the inflammation seems to have been excited by cold 
or exposure, and it may follow severe burns. Cases of acute serous or 
suppurative peritonitis are occasionally seen which are apparently pri- 
mary. I have met with two such in young children which were due to 
the streptococcus. 

The secondary form is more common. The most frequent of all 
causes is appendicitis, which should always be suspected in acute perito- 
nitis occurring without definite cause. Extension of inflammation from 
the viscera to the peritonaeum is very much less frequent in children than 
in adults. I have seen it but once in autopsies in acute intestinal dis- 
eases. It is also rare in typhoid fever, being noted but twice among my 
collected cases. It is occasionally due to abscess of the liver, ulcer of 
the stomach, acute intestinal obstruction from internal strangulation, 
intussusception, volvulus, or congenital atresia. It may extend from in- 
flammation of the pleura. This may be in the form of an empyema which 
burrows through the diaphragm, or, without burrowing, the infection 
may take place through the lymph channels; or it may be secondary 
to a general pneumococcus septicaemia. Peritonitis is infrequently due 
to infection through the female genital tract, especially in gonococcus 
vulvo-vaginitis in older girls. Extension of inflammation from the 
male genital organs is very rare. In one case at the Xew York Infant 
Asylum, fatal peritonitis in an infant started from a suppurative in- 
flammation of the tunica vaginalis of unknown origin, the infec- 
tion extending into the peritonaeum through the inguinal canal. 



ACUTE PERITONITIS. 443 

Any abscess in the neighbourhood may rupture into the peritonaeum 
and excite peritonitis. Those most frequent in children are con- 
nected with. Pott's disease, perinephritis, and cellulitis of the abdominal 
wall. 

Of the acute infectious diseases, peritonitis is most frequently seen 
with pneumonia, and very rarely with scarlet fever. When secondary to 
pneumonia, there is usually extreme pleurisy and sometimes also peri- 
carditis and meningitis ; in other words a general pneumococcus infection 
is present. 

The bacteria most frequently associated with acute peritonitis in chil- 
dren are: the streptococcus, especially in the newly born; the pneumo- 
coccus in cases complicating pneumonia or empyema; and the o. coli 
communis, associated with other pyogenic bacteria, in those following 
intestinal perforation. 

Lesions. — In the fibrinous form there are changes similar to those 
occurring in inflammation of the pleura and the other serous membranes. 
The peritonaeum is injected and fibrin is thrown out in considerable 
quantity, usually accompanied by a small amount of serum. The process 
is usually a localised one. The peritonaeum lining the abdominal wall, 
as well as that covering the adjacent coils of intestine and the solid 
viscera, is covered by patches of yellowish-gray fibrin, causing adhesions 
between the various viscera and often matting the intestines together. 
In recent cases these adhesions are soft, and easily broken down; in old 
cases they are quite firm, and they may result in the formation of con- 
nective-tissue bands which are the source of subsequent trouble. In 
other cases the serum is more abundant, usually clear, but it may be 
turbid or even bloody. 

In the purulent form the products are serum, fibrin, and pus. When 
peritonitis results from perforation it is, as a rule, purulent from the 
outset, and the pus is foul and stinking. The amount of pus is pro- 
portionally larger than in adult cases. When the disease proves fatal 
in a few days there is found an extensive exudation of fibrin, with the 
formation of small pockets containing pus, among the coils of intestine. 
Occasionally there may be larger collections of pus in the peritoneal 
cavity. In cases which have lasted a longer time — generally those of 
localised inflammation — the process results in the formation of a peri- 
toneal abscess. This consists in a collection of pus in some part of the 
peritoneal cavity, the situation depending upon the cause, but it is 
usually in one iliac fossa or in the pelvis. The abscess is shut off from 
the rest of the peritoneal cavity by a thick wall of fibrin. If left alone, 
such abscesses may open into the rectum, vagina, bladder, pelvis of the 
kidney, or externally, usually at the umbilicus. After the discharge of 
pus the cavity may contract and fill up by granulations, and the patient 
recover. 



444 DISEASES OF THE DIGESTIVE SYSTEM. 

Inflammations of the other serous membranes, especially the pleura, 
are often associated with peritonitis. 

Symptoms. — The symptoms of acute peritonitis in older children, as 
in adults, are usually well marked and sufficiently characteristic to enable 
one to recognise the disease easily ; but not so in the case of infants. In 
them the symptoms are often obscure, and the disease may be found at 
autopsy when not suspected during life. The onset is nearly always 
abrupt, with fever and vomiting. As a rule, the temperature is high — 
from 103° to 105° F. Vomiting may occur only at the onset, but it 
often continues; the vomited matters are usually green. Older children 
complain of pain, which may be localised or general; and in younger 
ones this is indicated by crying and fretfulness. The abdomen very soon 
becomes swollen and tympanitic, this being one of the most constant 
features of the disease. The distention is generally uniform, but it may 
be irregular. There is tenderness on pressure, and usually marked rigid- 
ity of the abdominal walls. The pain causes the child to assume a fixed 
position and he cries if moved or disturbed. The posture is generally 
dorsal, with the thighs flexed. The bowels are in most cases constipated, 
but diarrhoea is by no means rare. The abdominal distention causes 
dyspnoea and thoracic breathing. There may be retention of urine or 
frequent micturition. 

The general symptoms, almost from the beginning, are those of a 
serious disease. The pulse is small, rapid, and compressible. The 
prostration is great, from the very outset. The face is pinched, the 
mouth is drawn, and the features indicate pain. In severe cases there 
may be hiccough, cold extremities, clammy perspiration, and collapse. 
The mind is usually clear. In infants there may be convulsions. A 
polymorphonuclear leucocytosis is almost invariably present, but is want- 
ing in some cases of the gravest type. 

In the most severe forms of general peritonitis the course is short 
and intense, and the disease goes on rapidly from bad to worse until 
death occurs. In infants this is often on the third or fourth day. The 
very severe forms of general peritonitis in older children run the same 
rapid course. In other cases the course is slower, lasting a week or ten 
days. If the patient lives longer than this the case is more hopeful, 
because the process is more apt to be localised. The development of 
peritoneal abscess is indicated by the continuance of the temperature, 
which may assume a hectic type, and be accompanied by chills and 
sweating. There are the local signs of an abdominal tumour. 

Prognosis. — Acute general peritonitis, whatever its cause, is a very 
serious disease in childhood. Of eighty cases of all varieties under 
sixteen years of age, sixty-nine per cent died. In the newly born and 
in infancy the disease is almost invariably fatal. In older children the 
outlook is not quite so hopeless, and depends upon the exciting cause. 



CHRONIC PERITONITIS. 445 

Treatment. — The medical treatment of acute general peritonitis in 
children is extremely unsatisfactory, as the disease is almost always fatal 
unless it can be relieved surgically. Opium is indicated only for the re- 
lief of the single symptom, pain. It has, however, serious disadvantages 
in that it may mask important symptoms. Other medical treatment is 
symptomatic only and is to be employed in conjunction with surgical 
measures. 

As a local application cold is usually to be preferred. It may be 
applied either by an ice-bag or by a Leiter's coil. If children rebel 
against the use of cold, heat may be substituted. Turpentine stupes may 
aid in relieving tympanites. 

Feeding is always a difficult matter on account of the strong tend- 
ency to vomit; this is due to regurgitation from the intestine into 
the stomach, which in some cases is almost continuous. In such con- 
ditions I have found great benefit from washing the stomach shortly 
before feeding, repeating this several times each day. In this way vomit- 
ing may often be controlled and the stomach made ready for food. The 
diet should be peptonised milk, broth, or kumyss. 

In every case of acute peritonitis, an immediate exploratory operation 
should be done if the child's general condition will permit. Appendicitis 
is often found to be the cause when least expected; and even when the 
peritonitis is due to some other cause operation gives the only chance 
for recovery. Operation is also indicated in localised inflammations with 
the formation of peritoneal abscesses. 

CHRONIC (NON-TUBERCULOUS) PERITONITIS. 

Peritonitis may occur in fcetal life with the production of extensive 
adhesions, which may interfere with the development of the intestine and 
result in various malformations. These cases have been ascribed by 
Silbermann to syphilis. 

Chronic peritonitis may follow the acute form, in which there are 
left adhesions which slowly increase owing to the production of new 
connective tissue. Such cases are sometimes chronic from the be- 
ginning. 

The peritoneal abscesses which follow the suppurative form may 
run a chronic course. Chronic localised peritonitis may occur in connec- 
tion with disease of any of the organs covered by the peritonaeum. 

Chronic Peritonitis with Ascites. — In most cases this is chronic from 
the outset and independent of the causes above mentioned. By far the 
most frequent form of inflammation is that due to tuberculosis, and by 
some writers the opinion is still held that chronic peritonitis with ascites 
is always tuberculous. After the observations reported by Henoch, Vier- 
ordt, Fiedler, and others, there seems to be no longer any room for doubt- 



446 DISEASES OF THE DIGESTIVE SYSTEM. 

big the existence of a chronic non-tuberculous form of peritonitis with 
ascites, although it must be considered a rare disease. In its pathological 
and clinical aspects it is to be compared to subacute or chronic pleurisy 
with effusion. 

Etiology. — Nearly all the cases thus far reported have occurred 
in children over six years old. The causes are for the most part ob- 
scure. It may be associated with disease of the intestines or the solid 
viscera of the abdomen, especially with new growths of the kidney, 
liver, etc. 

Lesions. — The post-mortem observations thus far have been few. In 
the reported cases there has been found a large amount of greenish 
serum in the general peritoneal cavity, with a very moderate amount of 
fibrin and with adhesions, which are sometimes few and sometimes very 
numerous. Chronic pleurisy may be associated. 

Symptoms. — The early symptoms are of a very indefinite character, 
but often nothing whatever is noticed until the swelling of the abdomen 
begins. The enlargement comes on rather gradually in the course of a 
few weeks. Pain is slight, or wanting altogether. There may be some 
abdominal tenderness. The abdomen is usually distended with fluid, the 
umbilicus protruding, and the superficial veins prominent. The enlarge- 
ment is generally regular and symmetrical, and the wave of fluctuation 
is readily obtained. The general symptoms are very few. In some 
cases there is a slight evening rise of temperature of one or two de- 
grees. There may be general weakness, loss of appetite, and moderate 
anaemia. 

The usual course of the disease is for the fluid to remain for a 
time and then undergo slow absorption. In some instances there -is no 
tendency to absorption of the fluid, the general health is gradually un- 
dermined, and the patients die from exhaustion or from some inter- 
current disease. The diagnosis rests upon the presence of ascites, devel- 
oping gradually without any signs or symptoms of disease in the heart, 
liver, or other organs. The points which distinguish it from tuberculous 
peritonitis are considered under that disease. The prognosis must be 
guarded on account of the difficulty in making a positive diagnosis from 
the tuberculous form. 

Treatment. — It is important that the patient should be kept at rest, 
preferably confined to bed. The best results are obtained by the adop- 
tion of a general tonic plan of treatment. When there is no tend- 
ency to absorption after a thorough trial of the above measures, and 
especially when the patient's general health begins to suffer, the fluid 
should be removed by paracentesis. If it continues to accumulate after 
repeated tapping, laparotomy may be performed, for in some cases 
this has the same beneficial effect as in tuberculous peritonitis. 



TUBERCULOUS PERITONITIS. 447 



TUBERCULOUS PERITONITIS. 

The peritonaeum is quite frequently the seat of tuberculous inflam- 
mation in early life. It occurs especially between the ages of one and 
five years, but is infrequent during the first year. Of 100 cases observed 
by Still, the largest number were seen in the second year of life. In 
255 autopsies upon tuberculous patients, most of them under three years 
old, of which I have records, the peritonaeum was involved in 8 . 6 per cent ; 
but in a majority of these the peritonitis was not the most important 
lesion nor the cause of death. Tuberculous peritonitis is apparently 
much more frequent in Europe than in this country. Thus, Still states 
that this was the cause of death in 16.8 per cent of his tuberculous 
patients under twelve years of age, and in 12 per cent of the deaths 
from tuberculosis under two }*ears. In 105 autopsies, for the most part 
upon older tuberculous children, Ashby found the peritonaeum involved 
in 36 per cent. In 883 collected autopsies upon tuberculous children of 
all ages, Biedert found the peritonaeum involved in 18.3 per cent. 
These figures do not represent the number of cases of tuberculous peri- 
tonitis, as in many of them only a few miliary tubercles were present. 

It is possible for peritonitis to occur as the primary lesion of tuber- 
culosis, the bacilli entering by way of the intestine, causing no lesion of 
the mucous membrane, but in the great majority of cases it is secondary 
to tuberculosis of the intestine, the mesenteric glands, the pleura, or 
to that of more distant parts, such as the lungs, the bronchial glands, 
etc. In a small number of cases there is a history of some local excit- 
ing cause, such as a fall or blow upon the abdomen. The bovine type of the 
tubercle bacillus is more frequently found in tuberculous peritonitis than 
in any other form of tuberculosis, possibly excepting cervical adenitis, 
which fact is strongly suggestive of milk as the source of infection. 

Tuberculous peritonitis is usually associated with other abdominal 
lesions — tuberculosis of the mesenteric glands, intestinal ulceration, etc. 
It is very rarely acute, but usually occurs as a subacute or chronic disease. 

The peritonaeum may be involved as one of the lesions in acute or 
subacute general miliary tuberculosis. This is the most common form 
seen in infants. The lesions consist in a deposit of miliary tubercles, 
which are generally rather sparsely scattered over the peritonaeum. The 
evidences of inflammation are very slight, or they may be absent alto- 
gether. These cases do not come under observation as cases of peri- 
tonitis, as there are no abdominal symptoms. 

The principal anatomical and clinical varieties of tuberculous 
peritonitis are the ascitic and the fibrous forms. 

The Ascitic Form. — This is much less frequent than the fibrous form. 
The peritonaeum is thickly sown with miliary tubercles, both discrete 



448 DISEASES OF THE DIGESTIVE SYSTEM. 

and in conglomerate masses. They are found in the omentum and the 
mesentery, upon the surface of the intestines and the solid viscera. 
The peritonaeum shows in varying degrees the changes of acute or sub- 
acute inflammation. There is congestion, with the production of a mod- 
erate amount of fibrin and a large amount of serum. In the most acute 
cases the fluid is in the general peritoneal cavity. In those of longer 
duration it may be sacculated. The fluid is usually abundant, but not 
excessive. It is most commonly an olive-coloured serum, but it may be 
sero-purulent, or even bloody. There are commonly other lesions of 
tuberculosis in the body, but they are usually less marked than those 
of the peritonaeum. 

Clinically, ascitic cases usually present the symptoms of a low grade 
of peritoneal inflammation. The onset is gradual, with indefinite gen- 
eral symptoms. There is usually some fever — 100° to 101 . 5° F. There 
is general weakness, prostration, and some loss of flesh, but not rapid 
emaciation. Vomiting is not prominent, and pain and tenderness are 
often absent. There may be nothing distinctive until distention of the 
abdomen is seen. This at first is due to intestinal gas, but later to fluid, 
which may accumulate in sufficient quantity to fill the general peritoneal 
cavity. The bowels may be constipated or there may be diarrhoea. In 
other cases there may be only a slowly developing ascites without any 
inflammatory signs, and the abdominal enlargement is practically the 
only symptom. 

The ascitic form of tuberculous peritonitis may result fatally, death 
occurring from general' tuberculosis or by slow exhaustion from the local 
disease ; the duration under these conditions is usually from two to four 
months. At other times the fluid may gradually undergo absorption 
and recovery take place, or after absorption the fibrous form of inflam- 
mation may develop. 

The Fibrous Form. — This is generally slower in its development and 
more chronic in its course than the ascitic form. There is a tuberculous 
inflammation, the products of which have undergone transformation into 
fibrous tissue. The most important feature of these cases is the pro- 
duction of extensive organised adhesions between the solid viscera and 
the intestines, between the intestinal coils, and between the intestines 
and the abdominal walls. The intestines may be compressed against the 
spine by bands. 

These adhesions and their mechanical consequences are sometimes 
almost the only lesions present. In other cases there may be an ac- 
cumulation of fluid, which may be sacculated or in the general peritoneal 
cavity. This may be serous, sero-purulent, or purulent. The omentum 
may be greatly thickened. There are often present in the fibrous exu- 
date covering the intestines, in the omentum, and in the mesentery, tu- 
berculous deposits consisting of caseous nodules or larger caseous masses, 



TUBERCULOUS PERITONITIS. 449 

which are frequently softened at the centre. Tuberculous deposits are 
found upon the peritoneal surface of the intestine, and infiltrate the 
intestinal walls, often leading to perforation, and sometimes to fistulous 
communications between adherent intestinal coils. There may also be 
tuberculous infiltration of the abdominal walls, accompanied by cellu- 
litis, resulting in abscesses, which may open externally, usually in the 
neighbourhood of the umbilicus. 

Clinically, these cases are distinguished by their slow, irregular course. 
They are the most chronic of all the forms. The onset is generally in- 
sidious, and fever is commonly absent. There is rarely vomiting. The 
bowels may be constipated or loose. For a long time the general health 
may remain good. The only characteristic symptom is the enlargement 
of the abdomen. In the early part of the disease this is chiefly from the 
tympanites, but later there may be some accumulation of fluid. It is 
rare that the inflammation remains entirely fibrinous. Ascites usually 
develops very slowly, but may be abundant. The adhesions of the in- 
testines may give rise to irregularities in the outline of the abdomen. 
Ascites may be present for a time and then disappear spontaneously, 
and the general health may so improve that the patient is considered quite 
well. There may even be a permanent cure. In other cases, after 
symptoms have been absent for some time, relapses occur, and more 
fluid is poured out. In addition to these symptoms, others are present 
depending upon the mechanical effects of pressure from the contracting 
adhesions. There may be more or less constriction of the intestine, 
pressure upon the vena cava, the renal or portal veins, the thoracic duct 
or its branches, or upon the stomach. These conditions may give rise 
to dyspeptic symptoms, emaciation, oedema of the lower extremities, and 
albuminuria. In some cases tuberculous peritonitis is entirely latent, 
and it is discovered at autopsy when there have been either no abdominal 
symptoms during life, or only colicky pains of an indefinite character. 
The course of this form of peritonitis is slow and irregular; it generally 
lasts for from six to twelve months, although with intermissions and 
exacerbations it may extend over several years. 

If softening and breaking down of inflammatory products take place, 
well-marked constitutional symptoms are usually present. These are 
partly, from the peritonitis and partly from general tuberculosis. Fever 
is regularly present, the temperature usually ranging from 99° to 102° 
F. Sometimes it assumes a distinctly hectic type. There is progressive 
emaciation, anaemia, prostration, and sweating. Diarrhoea is frequent, 
and the intestinal discharges may at times be bloody. The abdomen is 
large, but not so much distended as in some of the other forms; the 
superficial veins are often prominent. Ascites often can not be made 
out by percussion, although fluid can often be found by puncture. Areas 
of dulness and tympanitic resonance are irregularly distributed. Nodu- 
30 



450 DISEASES OF THE DIGESTIVE SYSTEM. 

lav masses of various sizes and irregular shapes may be felt anywhere in 
the abdomen, but they are more frequently in the region of the umbilicus 
and in the right iliac fossa than elsewhere. The epigastric region may 
be occupied by a smooth, hard tumour — the thickened omentum — which 
may resemble the liver. There may be the signs of phlegmonous inflam- 
mation of the abdominal wall in the neighbourhood of the umbilicus, 
and even an abscess, which, after opening, may leave a fistulous com- 
munication with the peritonaeum. There are usually some signs of dis- 
ease in the lungs, and the pulmonary symptoms may mask those of the 
abdomen. The course of the disease, when softening and breaking down 
have taken place, is steadily progressive, the usual duration being from 
three to six months. Death results from the pulmonary disease, from 
tuberculous meningitis, from exhaustion, and occasionally it is due to 
accidents associated with perforation. 

Diagnosis. — The essential symptoms of tuberculous peritonitis are an 
enlarged abdomen, often with evidence of fluid, wasting, colicky pain, 
irregularity of the bowels, nodular masses in the abdomen, and usually 
slight but continuous fever. In young children chronic ascites with 
fever usually means tuberculous peritonitis. Pouting of the navel, with 
induration and redness about it, is suggestive, and any chronic abscess 
in the neighbourhood of the umbilicus is suspicious. If the abdominal 
effusion is sacculated instead of diffuse, the probabilities of peritonitis 
are much increased. If there are added physical signs pointing to dis- 
ease of the lungs or the evidence of tuberculosis elsewhere, or a positive 
tuberculin reaction, cutaneous or otherwise, the diagnosis is almost cer- 
tain. Cirrhosis of the liver is practically unknown in infancy and early 
childhood. If ascites is absent, tuberculosis of the peritonaeum may be 
suspected if there are irregular nodules or masses in various parts of the 
abdomen, with tenderness, emaciation, colicky pains, and, in the later 
stages, fever. But fever may be absent for a long time, even though local 
symptoms are marked. The epigastric tumour due to omental thickening 
may be mistaken for the liver; but it generally extends quite across the 
abdomen, and the upper as well as lower border can often be felt. 
Faecal masses may resemble tuberculous deposits, but are removed by 
cathartics and enemata. 

The examination of the fluid drawn by aspiration is not of much as- 
sistance in diagnosis. Bacilli are very difficult to demonstrate; only by 
animal innoculations can the tuberculous nature of the fluid usually be 
proven. 

Prognosis. — Tuberculous peritonitis is always a serious disease, but 
by no means a hopeless one ; rather more than half of all cases recover. 
The younger the child the worse the outlook. It is especially bad during 
the first year. Many cases occurring in the second year and later re- 
cover spontaneously and entirely. The most hopeful ones are those with 



TUBERCULOUS PERITONITIS. 451 

ascites. But even in the fibrous form some apparently complete recov- 
eries take place, the adhesions disappearing by absorption to a degree 
truly remarkable. The most unfavourable cases are those in which 
there is strong evidence of the breaking down of tuberculous deposits, 
with continuous fever and wasting. 

Treatment. — The general treatment of tuberculous peritonitis is sim- 
ilar to that of tuberculosis in other parts of the body. The essentials are, 
rest, which should be invariably in the recumbent position, a climate 
mild enough to permit the patient to remain out of doors the greater 
part of the time, and very careful attention to feeding, with the purpose 
of improving the general nutrition. Under this treatment a very con- 
siderable number of patients recover, especially those who are over a 
year old. Such a termination is more likely if the diagnosis has been 
made early and if the disease is limited to the peritonaeum. Drugs play 
but a small part in the treatment of these cases, but it is the general 
opinion that creosote is of some value. The carbonate may be used, or 
the creosote itself may be given in " pearls " or in emulsion. English 
authorities still attach considerable importance to the use of iodoform, 
which may be used, though somewhat cautiously, by inunctions (twenty 
grains to one ounce of olive oil), or it may be given by mouth in pill 
form, in doses of one-third to one-half grain three times a day. A 
faithful trial of these measures should be made before resorting to 
operation. The use of tuberculin as a therapeutic measure in these 
cases has not yet been tested sufficiently to enable one to speak with any 
positiveness of results; it demands further trial. 

In cases not progressing favourably under medical treatment, the 
question of operation should be considered. The most favourable cases 
for operation are those of the ascitic variety. It may be useful also with 
localised or general suppuration and for the relief of intestinal obstruc- 
tion occurring in the course of the disease. In the fibrous form less is 
to be expected from it. Operation may be done for the relief of recur- 
ring colicky pains due presumably to constriction by bands. Exploratory 
laparotomy is indicated in all cases of doubtful diagnosis. The exist- 
ence of other foci of tuberculosis does not contraindicate operation ex- 
cept when these are chiefly intestinal, or when there is advanced general 
tuberculosis. 

Aldibert has collected statistics of 52 operations, with 7 deaths and 
45 recoveries. Nine patients were reported well one year after opera- 
tion. It is possible that among these cases some of simple inflammation 
were included; of 18 cases, however, in which the diagnosis of tubercu- 
losis was established by the microscope or inoculation experiments, all 
recovered, and 6 were well one year after operation. Why it is that 
simply opening the abdomen and draining or washing out the peritoneal 
cavity should have such an influence in arresting the disease, which, in a 



452 DISEASES OF THE DIGESTIVE SYSTEM. 

certain proportion of instances, is certainly the case, has not yet been 
satisfactorily explained. In deciding the question of operation, its un- 
favourable results should also be borne in mind. A not uncommon 
consequence is injury to the intestine from the breaking up of adhesions, 
which may result in faecal fistulae. For the surgical aspect of the treat- 
ment the reader should consult works upon surgery. 

ASCITES. 

Ascites consists in an accumulation of fluid, usually clear serum, in 
the general peritoneal cavity. It is a symptom of the various forms of 
peritonitis, especially the chronic varieties described in the preceding 
pages. It may be due also to portal obstruction from cirrhosis of the 
liver, or pressure upon the portal vein by peritoneal adhesions or large 
lymphatic glands. It is occasionally seen in all forms of abdominal 
tumours. Ascites may occur in general dropsy from cardiac disease, 
chronic pleurisy, or interstitial pneumonia, or from any condition caus- 
ing pressure upon the vena cava. It is also seen in the general dropsy 
of renal disease. A moderate amount of ascites is often met with in 
extreme anaemia or leukaemia. 

Small accumulations of fluid in the peritoneal cavity are difficult of 
detection. Large amounts are generally easily made out. There is a 
uniform smooth distention of the abdomen and dilatation of the super- 
ficial veins, especially about the umbilicus. On palpation, the wave of 
fluctuation can be obtained by placing one hand against the abdomen 
upon one side and giving the opposite side a sharp tap. A similar wave 
may be felt when there is tympanitic distention. The two are, however, 
readily distinguished by having an assistant make pressure with the 
edge of the hand along the linea alba while the test is being made ; this 
obstructs the wave transmitted through the abdominal wall, but does 
not affect that through the fluid. On percussion in the sitting posture, 
there is dulness below and resonance above. When the patient is re- 
cumbent, there is resonance in the median line and dulness or flatness 
in the lateral portion of the abdomen. 

The prognosis and treatment of ascites will depend upon its cause. 

Chylous Ascites. — This term is applied to certain cases in which the 
abdominal fluid contains fat. The colour may be milky-white or light 
brown, and the fluid, after standing, may have at its surface a thick, 
creamy layer. The amount of fat present has been as high as five per 
cent. This condition is rare in childhood. The exact pathology is as 
yet not well understood. In the cases which have thus far come to 
autopsy there has usually been found chronic peritonitis, sometime? 
simple, sometimes tuberculous. The lymph vessels in some of the cases 
have been empty, and often no obstruction of the lymph circulation 



SUBPHRENIC ABSCESS. 453 

could be discovered. The fat is believed by some to be derived from 
fatty degeneration of the products of chronic inflammation, but this 
seems hardly sufficient to explain the large amount of fat sometimes 
found. In some of the cases it has been due to a wound of the thoracic 
duct. The amount of fluid is frequently very large. The prognosis is 
usually bad, although Pounds has reported a case in a girl of ten years, 
where recovery followed laparotomy. Tuberculous peritonitis was present. 

SUBPHRENIC ABSCESS. 

In the group of cases of localised peritonitis or peritoneal abscess, 
must be included subphrenic abscess. This is a rare condition in child- 
hood, and consists in an accumulation of pus just beneath the diaphragm 
and above the liver. Its cause may be either in the thorax or in the ab- 
domen. It may complicate acute pneumonia, usually of the right lower 
lobe, by a direct extension of infection through the lymph channels. 
Sometimes it has been associated with phthisical cavities. In the abdo- 
men it may be associated with disease of the liver. The accumulation of 
pus is sometimes very great, so that the diaphragm is crowded high into 
the thorax. 

The symptoms and physical signs closely resemble those of empyema, 
and most of the cases have been operated upon with the belief that the 
surgeon was dealing with empyema. Meltzer has reported a case in a 
child of two years which followed pneumonia of the right base. At the 
operation only a few drops of pus were found in the pleural cavity; but 
there was discovered a pinhole opening in the diaphragm, from which the 
pus had escaped from a large subphrenic abscess. This was evacuated, 
and the patient recovered perfectly. Subphrenic abscesses may contain 
air; they are then likely to be mistaken for pneumothorax. These ab- 
scesses require incision and drainage like other forms of peritoneal 
abscess. 



SECTION IV. 
DISEASES OF THE RESPIRATORY SYSTEM. 

CHAPTER I. 
NASAL CAVITIES. 

ACUTE RHINO-PHARYNGITIS. 

(Acute Nasal Catarrh-Coryza.) 

Although the symptoms of acute nasal catarrh are chiefly nasal, the 
principal seat of the pathological process is the rhino-pharynx. 

Etiology. — Certain children are predisposed to attacks of acute nasal 
catarrh. This predisposition, as it sometimes extends to entire fam- 
ilies, may be inherited; but more frequently it is acquired, and usually 
by the following mode of life : It is seen in children who get very little 
fresh air, because they are kept indoors unless the weather is perfect; 
who live in houses always overheated; whose sleeping rooms are kept 
carefully closed at night for fear they may take cold; who are for the 
same reason so overloaded with clothing that they can not engage in 
any active play without being thrown into a profuse perspiration. These 
conditions after a time result in a great sensitiveness of all the mucous 
membranes, but especially those of the nose and pharynx, which is much 
increased by residence in a damp, changeable climate. Young infants 
and those who are rachitic, are frequent sufferers from acute nasal 
catarrh. Attacks are often brought on by insufficient covering for the 
head, by wetting the feet, by cold and exposure, especially to street dust 
and the raw winds of winter and spring, accompanied by the damp- 
ness which occurs with melting snow. In susceptible children the ex- 
citing cause is often a very trivial one. A draught of cold air for a 
few minutes may be sufficient to excite sneezing and a nasal discharge. 
Atmospheric conditions are probably not the only cause of acute nasal 
catarrh. Micro-organisms certainly play an important part, particularly 
the staphylococcus aureus, pneumococcus, streptococcus, and the b. in- 
fluenza?, their importance being in the order named. Although pyogenic 
germs are always present in the nose, they do not excite an attack of 
acute catarrh without the vascular changes which are produced by other 
causes. Acute catarrh may be sporadic or epidemic; certain forms are 
454 



ACUTE RHINO-PHARYNGITIS. 455 

contagious, being communicated by children using the same handker- 
chief, occupying the same bed or simply by close contact. 

Acute nasal catarrh may be a symptom of measles, nasal diphtheria, 
or influenza, and it may accompany erysipelas of the face. 

Symptoms. — In the mild form the changes in the mucous membrane 
of the nose are not great, and are usually secondary to those of the rhino- 
pharynx, being in a large measure due to the discharge. There is 
redness and slight swelling. The nasal passages may be for the time 
quite occluded by the discharge, which is usually profuse, at first sero- 
mucous, and later muco-purulent. The symptoms may be very transient, 
sometimes passing away in a few hours, in which cases there is only a 
vasomotor disturbance; or they may continue and develop into a true 
inflammation. The discharge may excoriate the nostrils and the upper 
lip. At the onset there is usually sneezing, and in infants often a slight 
fever. In older children there is no rise of temperature except in the 
most severe cases. The obstruction to nasal respiration causes mouth- 
breathing, and the dryness and discomfort which result from it produce 
disturbed sleep, snuffling and difficulty in nursing, this being in severe 
cases almost impossible. The inflammation may extend to the lachrymal 
duct, involving the eyes in a mild conjunctivitis. The process often 
extends to the larynx and bronchi, with hoarseness and cough. There 
may be closure of the Eustachian tubes, causing deafness and otalgia. 
The chief complication for which the physician should watch is otitis. 

The severe form in infants is often attended by marked constitutional 
symptoms ; the temperature may be as high as 104° or 105° F. and some- 
times fluctuates widely. The discharge soon becomes muco-purulent and 
is very profuse, pouring from the anterior nares and filling the pharynx. 
The cultures in this form most frequently show the pneumococcus and 
the staphylococcus aureus. Severe symptoms often continue for a week 
or more, the child being really seriously ill. Complications are almost 
always present. In most cases there is cervical adenitis and otitis. If the 
child is a delicate one broncho-pneumonia is apt to develop. Retro- 
pharyngeal abscess is not infrequently seen. 

Diagnosis. — It is important to distinguish between a simple acute 
catarrh and one due to measles, influenza, nasal diphtheria, or hereditary 
syphilis. Measles and influenza usually cause more fever and general 
constitutional disturbance than does simple catarrh. Nasal diphtheria 
may be present when there is only a profuse discharge tinged with blood. 
When such a discharge persists for two or three weeks this is always to 
be suspected, even though the constitutional symptoms may be very 
slight. The only positive means of excluding diphtheria is by cultures. 
A persistent acute nasal catarrh in a young infant should always suggest 
syphilis, and the patient should be carefully watched for the development 
of other symptoms. 



\M\ nisi asks OF THE RESPIRATOR? SYSTEM. 

Treatment. — A young child Buffering from acute coryza should be 
kept indoors in a room with an even temperature of about 70° F., the 
bowels freely opened, and the amount of food somewhat reduced. The 
only drug which seems to have much influence upon the secretion is 
belladonna. A good combination is that known as the "rhinitis" tablet 
(camphor, gr. \ ; quinine, gr. J; fluid extract of belladonna, IT), £) ; one- 
half a tablet may be given every hour to a child of five years. 

Useful local applications are liquid albolene, oleo-stearate of zinc, or 
alkaline sprays, such as Seller's solution, to clear away the secretions. 
If the nasal obstruction causes great interference with respiration or 
nursing, adrenalin diluted with a saline solution may be used with a 
medicine dropper. 

The upper lip and nostrils should be protected by vaseline or some 
simple ointment. Under no circumstances should irritating or astringent 
injections be given. In older children inhalations of spirits of camphor 
may be used with some advantage. 

The severe cases require more active treatment. For most of them 
nasal irrigation with a warm saline solution is to be advised. This 
should be done as in diphtheria. After cleansing the rhino-pharynx a 
few drops of a flve-per-cent solution of argyrol may be dropped into the 
nostrils two or three times daily. 

Prophylaxis consists in solving the perplexing question, so often 
put to the physician, of how to prevent children from " taking cold." 
This is a matter of the utmost importance, and follows what has been 
previously said under the head of Etiology. No amount of cod-liver oil 
and iron will remove this tendency to catarrh so long as bad hygienic 
conditions continue. Sleeping rooms should be large and well ventilated, 
and a w r indow should be kept open at night, except in very severe weather 
or during acute attacks. The temperature of the house during the day 
should be from 65° to 68° F., but never above this. Children should be 
accustomed to go out of doors unless the weather is especially bad. So 
firmly rooted in the minds of the laity is the idea that acute catarrhs 
co 1 1 Hi from cold, that the habit of coddling delicate children is always 
likely to be carried to an extreme. 

With every delicate and " catarrhal " child one should begin in the 
summer by having him live in the open air as much as possible, sleep- 
ing in a room with free ventilation, with moderate covering, and con- 
tinuing the same practice into the fall and early winter. If begun 
gradually in this way there is little difficulty in continuing throughout 
the winter. 

The next point to be insisted on is cold sponging immediately upon 
rising in the morning, especially about the chest, throat, and spine. The 
use of chest protectors, cotton pads, and extremely thick clothing should 
be prohibited. Flannel underclothing should be worn upon the chest 



CHRONIC NASAL CATARRH. 457 

throughout the year, and upon the Legs also in winter; the very lightest 
in summer, and only a medium weight in winter. 

Frequently repeated attacks point to the presence of adenoid vegeta- 
tions in the pharynx, and no measures are of much avail until these are 
removed. 

CHRONIC NASAL CATARRH. 

This term is rather loosely used to designate a chronic nasal dis- 
charge. Such a discharge is frequent both in infancy and childhood. 
It is a condition much neglected by the general practitioner. Patients 
are too often subjected to routine constitutional treatment by cod-liver 
oil and preparations of iodine, with the idea that such cases are " scrofu- 
lous," while local treatment is either neglected altogether, or consists 
only of the use of the nasal douche or syringing with a saline solution. 
Sometimes, when suggested by parents, local treatment is opposed by the 
physician in the case of young children, and a great amount of harm 
follows. Permanent damage to the organs of hearing, smell, speech, and 
respiration may result from neglecting or ignoring chronic nasal catarrh 
in childhood. 

Chronic nasal catarrh is not to be regarded as a disease, but only as 
a symptom which may be due to any one of a variety of pathological 
conditions, each of which requires very different treatment, viz., adenoid 
growths of the pharynx, foreign bodies in the nose, polypi, deviation 
of the septum or any other congenital deformity of the nasal passages, 
the various forms of chronic rhinitis, and syphilis, which causes a form 
of rhinitis peculiar to itself. 

Adenoid Growths of the Pharynx. — These are more fully discussed 
elsewhere. They are by far the most frequent cause of chronic nasal 
discharge in infants and young children, and should be the first sus- 
pected. Every general practitioner can easily familiarise himself with 
the method of digital exploration of the rhino-pharynx, by which means 
these growths can in most cases be easily recognised. The nasal dis- 
charge accompanying adenoid growths is due to a chronic rhino-pharyn- 
gitis. Treatment is without avail unless the growths are removed. After 
this is done the nasal discharge usually disappears quite promptly. 

Foreign Bodies in the Nose. — This condition should be suspected 
whenever there is an abundant muco-purulent discharge limited to one 
nostril. Foreign bodies in the nose are quite frequent in young children. 
Peas, beans, beads, or shoe buttons are most frequently lodged there. 
The efforts at removal on the part of the child, or even of the mother, 
generally result in pushing the body farther into the nose. It first sets 
up a mechanical irritation, accompanied by pain, swelling, snoozing, and 
sometimes haemorrhage. This is followed by a catarrhal inflammation, 
w r hich in the course of a few days becomes purulent, and may last in- 



458 DISEASES OF THE RESPIRATORY SYSTEM. 

definitely. The discharge is generally quite abundant. The symptoms 
point to an obstruction o( one nostril, and an examination with the probe 
readily detects the presence of the foreign body. 

In mom cases the removal of the foreign body may sometimes be 
accomplished by compressing the empty nostril and having the child 
blow his nose strongly. Often the sneezing which the foreign body ex- 
cites is sufficient to remove it. Before any attempt is made to seize the 
body with forceps cocaine should be used, not only for the purpose of 
preventing pain, but in order to contract the mucous membrane so as to 
allow better manipulation. In many cases chloroform is necessary. In 
most circumstances ordinary foreign bodies can with proper forceps be 
extracted without difficulty. Xo subsequent treatment is required, except 
the use of some mild antiseptic to keep the nose clean for a few days, 
as the inflammation quickly subsides after the removal of the cause. 

Nasal Polypi. — These are among the infrequent causes of chronic 
nasal discharge in childhood. They are especially rare before the seventh 
year, but both mucous and fibrous polypi are seen. The symptoms are 
those of a chronic nasal catarrh with partial or complete obstruction of 
one or both sides. Polypi increase in size with the occurrence of every 
acute coryza, and are always especially troublesome in damp weather. 
They may be accompanied by reflex symptoms, such as cough, sneezing, 
and even by attacks of asthma. There may be headache, and sometimes 
disturbances of smell, taste, and hearing. The symptoms are of much 
longer duration than in the case of obstruction from a foreign body, the 
discharge is not so abundant, and is not purulent. The diagnosis is 
made only by examining the nose with the mirror and nasal speculum. 

Polypi may be removed with the forceps, but this is best accomplished 
by the use of the wire snare. When they have been present for a long 
time the accompanying chronic rhinitis may require subsequent treat- 
ment. 

Deviation of the nasal septum, and other congenital deformities 
which cause narrowing of the nasal respiratory tract, are conditions 
which belong to the specialist. 



CHRONIC RHINITIS. 

Simple Chronic Rhinitis. — Simple chronic rhinitis existing alone is 
of rare occurrence in young children. In the cases so classed the symp- 
toms are usually due to rhino-pharyngitis, which almost invariably de- 
pends upon an adenoid growth. The growth may be a small one, so 
that the Bymptoms of obstruction are slight or absent. A frequent com- 
plication is chronic enlargement of the cervical lymph glands. 

The only constant symptom is an excessive nasal discharge which is 
usually mucous but which may be muco-purulent. It is easily removed 



CHRONIC RHINITIS. 1.7.) 

by blowing the nose, if the child is old enough to be taught to do this. 
Children too young to clear the nose in this way, Buffer from almost con- 
stant discomfort. The amount of discharge depends upon the severity of 
the case. It frequently causes irritation of the upper lip, which may be 
the seat of eczema or impetigo, especially in infants. The lip may bu 
swollen and prominent. The condition of the external parts is aggra- 
vated by the constant disposition to pick the nose, which may be over- 
come by the application of a short anterior splint to each elbow. 

Epistaxis sometimes occurs. The duration of the disease is indefi- 
nite; it may last for months or even for years, the symptoms in summer 
being insignificant, but returning every cold season. It may terminate 
in recovery, or, in children with flabby tissues and delicate constitution, 
it may be followed in later childhood by hypertrophic rhinitis. 

Treatment. — Prophylaxis is very important. The main purpose 
should be to prevent attacks of acute nasal catarrh by the measures men- 
tioned in the discussion of that disease. The general treatment should 
not be routine, but based upon the indications of each case. General 
tonic treatment is required in most cases. 

Local treatment consists first in cleanliness, and, secondly, in the use 
of astringents in the form of powder or solution. In infants, if the dis- 
charge is abundant, the only efficient method of getting rid of it is by 
nasal syringing. This is attended by some risk of forcing materials into 
the middle ear; but if carefully done, the danger seems to me to be less 
than that of allowing the discharge to remain. All solutions are to be 
made with sterile water and used warm, either with a nasal douche 
or syringe. A^ery little force should be employed, and it may be well to 
have a syringe the nozzle of which does not completely fill the nostril. 
Either Dobell's or Seller's solution may be employed, diluted with an 
equal amount of water. Ordinarily, the nose should be cleansed thor- 
oughly twice a clay, more frequently in very severe cases. Harm is often 
done by the overzealous use of local treatment in these conditions. 

Syphilitic Rhinitis. — Rhinitis is seen both in early and late hered- 
itary sj T philis. Coryza, or snuffles, is one of its earliest and most con- 
stant symptoms. It usually begins between the third and sixth weeks 
of life, rarely after the third month. The pathological condition is a 
subacute catarrhal rhinitis, sometimes with the formation of superficial 
ulcers or mucous patches. The disease is usually attended by a profuse 
nasal discharge of sero-mucus or muco-pus, occasionally tinged with 
blood. It may continue from a few weeks to two or three months. It 
usually requires only constitutional treatment, and protection of the 
nostrils and lips by the use of the ointment of the yellow oxide of mer- 
cury diluted with four parts of vaseline. When the discharge is very 
abundant, any one of the cleansing solutions previously mentioned may 
be used as a spray. 



400 DISEASES OF THE RESPIRATORY SYSTEM. 

The rhinitis of late hereditary syphilis is a very different patholog- 
ical condition. There are here gummatous deposits which break down, 
and form ulcers of the mucous membrane and deeper tissues. There is 
also periostitis, with extension of the disease to the cartilages and bones 
of the nasal fossa?, particularly of the septum. There may be perforation 
of the triangular cartilage, necrosis of the vomer or nasal bones, perfora- 
tion of the hard or soft palate, and at times extensive ulceration of the 
ala? nasi and the face. Cicatrisation may follow, causing stenosis of the 
nostril. These lesions in the nose are generally accompanied by deep 
ulceration of the pharynx and soft palate. They usually occur in chil- 
dren who have presented the early symptoms of hereditary syphilis, but 
are occasionally seen when no such history can be obtained. Such was 
the case in a patient recently under observation in the Babies' Hospital, 
who had perforation of the nasal septum and of the floor of the nasal 
fossa?, causing a free communication with the mouth. These are cases 
of true ozaena. The odour from the discharge is at times almost intoler- 
able. When neglected, these cases go on from bad to worse, and may 
continue for years, producing unsightly deformities. 

The constitutional treatment is that of hereditary syphilis in general 
and is discussed in the chapter upon that disease. 

Locally there may be used a spray of one of the cleansing solutions 
already mentioned, or black wash, or a solution of bichloride of mercury, 
1 to 10,000. Although improvement may take place quite promptly, the 
results of treatment in the late cases are often unsatisfactory, as the 
disease has usually progressed so far before treatment is begun that 
some deformity of the nose results, usually a sinking in of the bridge 
and flattening of the alse, giving rise to the so-called " saddle-back " 
deformity. 

EPISTAXIS. 

The haemorrhage may come from any part of the nasal fossae, but it 
is generally from the anterior nares, and most frequently from the vessels 
of the septum. Epistaxis is a rare symptom in the haemorrhages of the 
newly born, and when present indicates syphilis. It is infrequent 
throughout infancy, but in childhood it is quite common, occurring in 
boys more frequently than in girls. In the latter it is especially common 
about the time of puberty. Children who are kept much indoors in 
overheated apartments, and who have susceptible mucous membranes and 
flabby tissues, are particularly prone, to it. The exciting cause may be a 
local one, like a fall or blow; it may be due to picking the nose, or to 
any kind of mechanical irritation; it may be associated with nasal ca- 
tarrh; and it is often caused by a small ulcer upon the septum. An 
attack may be brought on by mental or physical excitement. It occurs 
as an occasional, often an early symptom, in typhoid or malarial fever, 



EPISTAXIS. 461 

in measles, or during severe paroxysms of pertussis. It is seen in the 
haemorrhagic form of all the eruptive fevers, in certain cases of diph- 
theria, in haemophilia and scorbutus, in grave anaemia, leukaemia, and in 
diseases of the heart and blood-vessels. 

Symptoms. — Epistaxis is frequently preceded by a sense of fulness or 
pain in the head, which is relieved by the bleeding. The blood is usually 
from one nostril, and comes slowly by drops. The amount lost is gen- 
erally small, but it may be large enough, when repeated, to produce a 
serious grade of anaemia even in strong children, and the haemorrhage 
may prove fatal. Epistaxis may be overlooked if the blood finds its way 
into the pharynx and is swallowed. In most of the cases the haemor- 
rhage ceases spontaneously in from ten to twenty minutes, recurring at 
longer or shorter intervals, according to the nature of the cause. Haem- 
orrhage from adenoid growths of the pharynx may closely resemble that 
from the nose, but otherwise there can rarely be any difficulty in recog- 
nising epistaxis. 

Prognosis. — This depends upon the cause. In the great majority of 
the so-called idiopathic cases epistaxis is not serious. Occurring early in 
the course of the infectious diseases, it does not ordinarily affect the prog- 
nosis unless it is very severe. When it occurs late, however, it is always 
a bad sign, and particularly so in diphtheria. It may be serious in any 
of the haemorrhagic diseases or in diseases of the blood, where it is not 
infrequently a cause of death. 

Treatment. — To remove the predisposition, a child should receive 
general tonic treatment, especially plenty of outdoor exercise, and every 
means should be taken, by the use of cold baths, friction, and proper food, 
to tone up the vascular system. 

An efficient means of arresting the haemorrhage is compression of the 
nose between the thumb and finger. This may be combined with the 
application of ice over the nose, and sometimes small pieces of ice may 
be introduced into the nostrils. The application of cold to the back of 
the neck or its use in the mouth may be of service by exciting reflex 
contraction of the capillary vessels. All tight clothing or bands about 
the neck should be loosened, and the patient kept quiet in the sitting 
posture. After the haemorrhage has ceased the child should not blow 
his nose for some time. Adrenalin is one of the most efficient local means 
of checking the bleeding. Another valuable remedy is the peroxide of 
hydrogen, used full strength. If bleeding continues in spite of all the 
above measures, the anterior nares should be plugged with styptic cotton, 
and if this does not control it, the posterior nares should be plugged. 
Usually very little effect is seen from drugs given internally, although 
in frequently recurring haemorrhages where no local cause can be dis- 
covered, calcium lactate should be tried; at least thirty of forty grains a 
day should be given to a child of five years. 



402 DISEASES OF THE RESPIRATORY SYSTEM. 

In severe cases o( nasal haemorrhage recurring at short intervals with- 
out any apparent cause, ulcer o\' the septum should be suspected, and, 
if present, should be touched with chromic acid. 



CHAPTER II. 

DISEASES OF THE LARYNX. 

The characteristic feature of laryngeal disease in infants and young 
children is the association of muscular spasm with all forms of inflam- 
mation. Often it is the laryngeal spasm, rather than the inflamma- 
tion, which gives rise to the principal symptoms. This spasm is only one 
expression of the great reflex irritability of young children. 

CATARRHAL SPASM OF THE LARYNX 

(Spasmodic Laryngitis; Spasmodic Croup; Catarrhal Croup). 

The term catarrhal spasm, first suggested, I think, by Goodhart, is 
fairly descriptive of this disease, which is characterised by a very mild 
degree of catarrhal inflammation associated with marked laryngeal 
spasm. 

Etiology. — It is not often seen during the first six months, but is 
frequent from this time up to the third year. After five years it is rare. 
It occurs in children w T ho are well nourished, as well as in those who are 
cachetic. Certain children have a predisposition to such attacks; those 
who have had one attack are likely to have others. The condition has 
many points of resemblance to spasmodic asthma which may replace it 
in later childhood. Heredity seems to have some influence in producing 
this extreme susceptibility of the air passages. Catarrhal spasm of the 
larynx is most frequently associated with enlarged tonsils and adenoid 
growths of the pharynx, sometimes with elongated uvula. The exciting 
cause may be exposure to cold, especially to high winds, or an attack 
of indigestion. 

Lesions. — The catarrhal inflammation of the larynx affects chiefly 
the parts above the cords; there is congestion and dryness, and later in- 
creased secretion of mucus. To this there is added a spasm of the 
muscles of the larynx, especially the adductors. There is no submucous 
infiltration, and no tendency to oedema glottidis. 

Symptoms. — The attack may be prece'ded for several hours by slight 
hoarseness, or by a nasal discharge. During the day the child may 
appear perfectly well. Usually there is heard during the evening a 
hollow, barking cough, at first infrequent and not seven 1 . About mid- 
night this is apt to increase in severity, and there is now difficulty in 



CATARRHAL SPASM OF THE LARYNX. lijij 

breathing. As soon as this becomes marked the child wakes, and presents 
the characteristic symptoms of an attack. In the mildesi cases the 
dyspnoea is not sufficient to waken the child. In severe cases there is 
marked dyspnoea, especially on inspiration, and a loud stridor as the air 
is drawn through the narrowed opening of the glottis. This may often 
be heard in an adjoining room. There is seen on inspiration deep 
recession of the suprasternal fossa, the supraclavicular spaces, and the 
epigastrium; also depression of the intercostal spaces, and even of the 
walls of the chest. Any excitement increases the spasm and aggravates 
the dyspnoea. The distress may be very great; the breathing usually 
slow and laboured; the voice hoarse, but rarely lost; the cough stridulous, 
hoarse, and metallic; the pulse rapid; the temperature normal or slightly 
elevated, rarely over 101° F. There may be slight lividity of the finger- 
tips and of the lips, and sometimes considerable prostration. In the 
course of three or four hours the attack slowly wears away and the child 
falls asleep. During the following day, aside from slight hoarse- 
ness and occasional cough, he is apparently well. Most of the cases 
are not so severe as this; there are the croupy cough, hoarseness, and 
general discomfort, but not marked dyspnoea. On the second night 
there is a repetition of the experience of the first, usually quite as 
severe unless affected by treatment; and on the third day a remission 
similar to that of the day previous. On the third night the attack, if 
it occurs at all, is generally a mild one. Slight hoarseness persists 
for several days, but otherwise the child is apparently well. Many 
children have such attacks every few weeks in the course of the cold 
season, the slightest exposure or an indiscretion in diet being sufficient 
to induce one. 

Prognosis. — This is good, the disease never, I think, proving fatal, 
although nothing is more alarming, at least to parents, than to witness 
for the first time one of these severe attacks of catarrhal croup. 

Diagnosis. — Catarrhal spasm may be confounded with laryngismus 
stridulus and with membranous croup. Laryngismus stridulus is rela- 
tively a rare disease, and occurs only in infancy. In it we have not 
simply stridulous breathing, but periods of complete cessation of respira- 
tion. These may be repeated many times during the day, and may con- 
tinue for weeks, being often complicated by carpo-pedal spasm, some- 
times by general convulsions. 

From membranous laryngitis, catarrhal spasm is distinguished by its 
sudden onset, the mildness of the symptoms of inflammation, the spas- 
modic character of the dyspnoea, and the daily remissions. The history 
of previous attacks will often aid in diagnosis. In case of doubt . a posi- 
tive diagnosis can often be made by allowing the child to inhale a little 
chloroform. This at once relieves dyspnoea due to spasm, while it has 
scarcely any effect upon that due to membrane. 



464 DISEASES OF THE RESPIRATORY SYSTEM. 

Treatment. — The purpose of treatment during the attack is to pro- 
duce relaxation of the Laryngeal spasm. This is accomplished by the use 
o( emetics, steam, and hot fomentations over the larynx. A favourite 
emetic- is a tablet triturate of antimony and ipecac, gr. 1 -J- g - each. To 
a child of two years, one tablet may be given every ten or fifteen minutes, 
until free vomiting occurs; or a teaspoonful of the syrup of ipecac and 
fifteen drops of the wine of antimony at the same intervals. Given at 
Longer intervals, these remedies are useful in relaxing spasm without 
causing emesis. When children do not vomit after two or three doses the 
antimony should not be repeated, as it may produce serious depression. 

Emetics have a double value if the attack is due to indigestion. If 
there is constipation, an enema should be given. Following the free 
vomiting there is generally some improvement in the symptoms, but 
there may be a recurrence of the spasm unless other means are em- 
ployed. To prevent this, antipyrine is one of the most useful drugs. 
One grain may be given to a child one year old. This may be repeated 
every two hours if necessary. Quite as much relief as that obtained from 
the drugs mentioned is seen from the use of steam inhalations. For 
this purpose the child should be placed in a closed tent, and steam intro- 
duced from a croup kettle. This may be used in conjunction with other 
measures, and continued as long as necessary. Poultices or hot fomen- 
tations over the larynx are often useful. In one case in which severe 
spasm had recurred for eight successive nights in spite of everything 
that was tried, the child being in great distress from the dyspnoea, 
I performed intubation, which gave instant relief. Tracheotomy, how- 
ever, would scarcely be advisable. 

During the day following the first night attack, the child should 
be kept in a warm room, and it is well to continue the antimony and 
ipecac in doses too small to produce vomiting, e. g., gr. y^-g- each, every 
four hours. After 6 p.m. the doses should be doubled, and at bedtime 
two grains of antipyrine given. If so treated, the symptoms may not 
recur upon the second night, or there may be only the cough without 
the severe dyspnoea. The child should be confined to the house for two 
or three days after one of these attacks, the drugs being gradually 
reduced; but the antipyrine should be given at bedtime for three or four 
successive nights. 

To prevent a repetition of the attacks and remove the tendency to 
them, it is most important that the child should have plenty of fresh air 
and cold bathing, especially cold sponging about the neck and chest. 
Everything which experience has shown to bring on the attack should be 
carefully avoided. Local causes, such as adenoid growths and hyper- 
trophied tonsils, should receive appropriate treatment. Generally it is 
not necessary to exclude fresh air from the sleeping room. Although an 
open window on a cold, damp night may sometimes excite an attack, 



ACUTE CATARRHAL LARYNGITIS. 466 

plenty of fresh air regularly given lends rather to diminish the raecep- 
tibility. If the child's condition is poor, general tonic treatment u to 
be employed. 

ACUTE CATARRHAL LARYNGITIS. 

Acute laryngitis is not nearly so frequent as the disease just described, 
although it is much more severe, and may even be fatal. It occurs espe- 
cially in children from one to five years of age, usually in the cold 
season. Predisposition to attacks is induced by the same conditions as 
in the case of acute rhinitis. Catarrhal laryngitis may be primary, when 
it is usually excited by cold or exposure, 1 or it may be secondary to 
measles, influenza, scarlet fever, or other infectious diseases. It may 
also be of traumatic origin, from the inhalation of steam or irritating 
gases. 

Lesions. — There is a moderately intense congestion of the laryngeal 
mucous membrane, sometimes general and sometimes localised. This 
may be seen with the laryngoscope, but is not always visible after death. 
With the congestion there are swelling and dryness, followed by increased 
secretion. In the milder cases the process is limited to the mucosa. In 
the more severe cases it involves the submucosa also, which is congested, 
oedematous, and may be infiltrated with cells. The changes are especially 
marked in the lymphoid tissue of the subglottic region. The swelling 
may be sufficient to produce a very marked degree of laryngeal stenosis. 
In many mild and in all the severe cases there is associated catarrhal 
inflammation of the trachea, and often of the larger bronchi. In young 
children there is very little tendency to oedema glottidis. 

Symptoms. — In the mild form, such as that which is usually seen in 
older children, there is hoarseness, or even loss of voice, and a laryngeal 
cough which is sometimes hard and teasing, always worse at night. 
There may be pain and soreness over the larynx. Constitutional symp- 
toms are mild or absent, the patient not usually being sick enough to go 
to bed, and often rebelling even at being kept indoors. The duration 
of the disease is from four to ten days, with a strong tendency to relapses 
from slight causes. 

The severe form of catarrhal laryngitis is sometimes preceded by 
acute coryza, or there may be mild laryngeal symptoms for a few days 
before the development of the more severe ones. In other cases the 

1 The following case is a good illustration of a severe attack excited by cold : A 
rather delicate infant, eight months old, an inmate of the New York Infant Asylum, 
was taken out, with very slight covering, on a raw December day. In a few hours 
hoarseness and stridor were noticed, and the temperature was 101° F.; three hours 
later it was 103° F. , and in spite of the usual remedies which were employed the dyspnoea 
had reached such a degree as to require intubation. The tube was worn only three 
days and the child made a prompt recovery. 
31 



4(H) DISEASES OF THE RESPIRATORY SYSTEM. 

disease develops rapidly and severe symptoms arc present within a few 

hours from the onset. 

When the case is fully developed the voice is metallic and hoarse, 
and occasionally lmt not usually lost. There is a hoarse, dry, barking 
cough, which is very distressing, and sometimes almost constant. The 
cough, like the voice, is Btridulous, and more or less stridor is present on 
inspiration. There is a slight amount of constant dyspnoea, but this is 
scarcely noticeable unless the chest is bared. Severe dyspnoea occurs in 
paroxysms, usually at night. Then, we may get the signs of obstructive 
dyspnoea similar to those mentioned in severe attacks of catarrhal spasm. 
This dyspnoea is chiefly inspiratory, but in some cases it increases stead- 
ily from the beginning of the attack, and may be indistinguishable from 
that due to membrane. Constitutional symptoms are usually present and 
may be severe. The temperature ranges in most cases from 101° to 
103° F., but may go to 10i° or 105° P. The pulse is rapid and full and 
respiration is accelerated. Children sometimes complain of pain in the 
larynx and trachea which is increased by coughing. The symptoms are 
severe for two or even three days, the fever continuing with moderate 
prostration and paroxysms of dyspnoea, sometimes even attacks of suf- 
focation and cyanosis. Usually after two or three days there is a grad- 
ual subsidence of the dyspnoea and the inflammatory symptoms, and the 
case goes on to recovery. At other times the inflammation extends down- 
ward to the large and then to the small bronchi, and finally results in 
broncho-pneumonia. The attack may prove fatal from laryngeal ob- 
struction due to swelling and spasm. 

Diagnosis. — This disease is chiefly to be distinguished from mem- 
branous laryngitis. The onset of the two diseases may be very similar, 
and for the first twelve hours w r e have no absolute means of distinguish- 
ing between them, except possibly by the use of the laryngoscope, which 
is often conclusive in older children but not usually so in infants. All 
cases, therefore, should be looked upon with a degree of apprehension. 
The temperature in the catarrhal is usually higher than in the mem- 
branous form. The dyspnoea is mainly paroxysmal, with daily remis- 
sions and nightly exacerbations, and is chiefly inspiratory, while that of 
membranous laryngitis is constant, steadily and often rapidly increas- 
ing, and is present both on inspiration and expiration. In catarrhal 
laryngitis the voice is not usually lost, but in the membranous form this 
is the rule. There can be little room for doubt when there are enlarged 
glands, membranous patches on the tonsils, and nasal discharge. Very 
often, however, all these evidences of diphtheria are "wanting, the really 
difficult cases being those in which the process begins in the larynx. The 
prevalence of diphtheria and a known exposure count for something in 
favour of membranous laryngitis. If cultures from the phar}*nx show 
the presence of Klebs-Loeffler bacilli, diphtheria of the larynx is certain; 



ACUTE CATARRHAL LARYNGITIS. 1(»7 

but no conclusions can be drawn from negative cultures. In catarrhal 
as well as in membranous laryngitis there may be extreme dyspnoea, 

cyanosis, pallor, prostration, and even death. 

Prognosis. — This depends somewhat upon the cause of the di 
and also upon the age of the patient. It is much worse when it if 
ondary to measles or scarlet fever. It is better in children over three 
years of age than in infants, also when the general condition of the child 
is good. The prognosis in severe catarrhal laryngitis should always be 
guarded, not only on its own account, but also because it is impossible 
at first to be certain that the case is not one of membranous laryngitis. 

Treatment. — In all cases children affected are to be kept in bed, and 
the temperature of the room should be between 70° and 72° F. The diet 
should be light and fluid, and the bowels should be freely opened. A 
hot mustard foot bath should be given at the outset. Antipyrine (one 
grain every two hours to a child two years old) is useful if there is 
much spasmodic dyspnoea. For this symptom emetics are beneficial, 
given as in catarrhal spasm. The use of ipecac and squills in smaller 
doses than is required for emesis (five drops each of the syrups of ipecac 
and squills every two hours) may give relief, especially in the early stage, 
when the cough is diy, hard, and severe. 

All the remedies mentioned are to be regarded as accessories to the 
essential treatment, which consists in the use of inhalations. The child 
should be placed in a tent into which steam is introduced from a croup 
kettle. Simple steam may be used, or turpentine, compound tincture 
of benzoin, lime-water, or creosote may be added. In moderately severe 
cases inhalations should be used for fifteen minutes every two hours; 
in very severe ones they should be continued the greater part of the 
time. Poultices or hot fomentations may be applied over the larynx. 
Relief is sometimes obtained by using counter-irritation by a mustard 
paste, but blistering should never be allowed. In my experience the 
local use of cold is very unsatisfactory, on account of the difficulty of 
applying it properly, and the objection to it on the part of young chil- 
dren. Stimulants may be required late in the disease, the amount of 
prostration being the guide to their use. 

In cases of extreme dyspnoea operative interference may be needed. 
It is required more often in infants and young children than in those 
who are older. Opinions will of course differ as to when the dyspnoea 
has reached the danger point. One should not wait for general cyanosis. 
If pallor, marked prostration, and steadily increasing dyspnoea are pres- 
ent the case should not be allowed to go on without interference, even 
though one may be perfectly sure that the case is one of catarrhal inflam- 
mation only. The severity of the dyspnoea is the only guide, and more 
than once I have seen cases shown at autopsy to be catarrhal, which were 
regarded during life as undoubtedly membranous. If intubation is done, 



468 DISEASES OF THE RESPIRATORY SYSTEM. 

the tube can generally be dispensed with in two or throe days. Con- 
valeecence is usually rapid, but there is danger of recurring attacks 
during the remainder of the cold season. 

SUBMUCOUS LARYNGITIS— (EDEMA OF THE GLOTTIS. 

These two conditions are not quite identical, although they are closely 
associated and may be conveniently considered together. They are both 
rare in early life. In true oedema of the glottis there is simply a drop- 
sical effusion into the submucous cellular tissue of the aryteno-epiglottic 
folds, causing them to project as large rounded swellings on either side 
of the superior isthmus of the larynx. They may be of sufficient size 
to cause serious or even fatal obstruction to respiration. With the laryn- 
goscope they appear as pale red tumours, lying usually in contact near 
the base of the tongue. By the finger their presence can be quite as 
readily distinguished. (Edema of the glottis occurs principally in the 
late stages of nephritis. 

In the inflammatory form of oedema, or true submucous laryngitis, 
there is the same sort of swelling of these structures, but in this case 
it is due to some active inflammation in the neighbourhood. The swell- 
ing is partly from the oedema and partly from cell infiltration. Usually 
all the parts surrounding the upper opening of the larynx are in a state 
of acute inflammation. The epiglottis may be swollen to the thickness 
of a finger, and easily seen by depressing the tongue. 

The exciting causes may be the mechanical irritation of foreign 
bodies, the inhalation of steam or irritating gases, erysipelas of the neck, 
primary catarrhal laryngitis, or retro-pharyngeal abscess. 

The symptoms in both cases consist of great inspiratory dyspnoea 
with attacks of suffocation, while expiration may be quite easy. In true 
oedema there are in addition the symptoms of the primary disease. In 
the inflammatory form there are the evidences of local inflammation — 
hoarseness, cough, pain, and difficulty in swallowing. A positive diag- 
nosis may be made by a digital examination. The symptoms develop 
with great rapidity in either variety, and frequently prove fatal in a 
few hours. 

The treatment of true oedema consists in scarification or multiple 
puncture, the application of ice externally, and even the swallowing of 
ice; in the inflammatory form, in addition, local blood-letting by leeches 
and, as a last resort, tracheotomy. Intubation is useless in either form. 

CHRONIC LARYNGITIS. 

The following varieties are seen: (1) A simple form usually asso- 
ciated with adenoid vegetations of the pharynx; (2) tuberculous; (3) 
syphilitic; (4) that associated with new growths. 



CHRONIC LARYNGITIS. 

1. With Adenoid Vegetations of the Pharynx.— This is not ?ery un- 
common. The larynx is kept in a state of chronic congestiou by the 
adenoid growth, and there finally develops a Blight superficial catarrhal 
inflammation. The symptoms may continue for many months. Tl 
cases are often treated for a long time unsuccessfully by th( 
sprays, inhalations, etc., but the symptoms disappear rapidly after the 
removal of the adenoid growth. Similar symptoms may I ited 
with hypertrophic rhinitis. In this also the treatment should he directed 
to the primary condition. 

2. Tuberculous Laryngitis. — This belongs t later childhood, and is 
rare even then. In infancy it is almost unknown. Kheindorf has re- 
ported a case in a child of thirteen months, which was regarded during 
life as syphilitic, but was shown by autopsy to be tuberculous. Of six- 
teen cases in children, reported by Eilliet and Barthez, none occurred 
during the first three years, and only four before the seventh year. The 
larynx alone may be affected, or the larynx and trachea, or the larynx, 
trachea, and lungs. Pulmonary tuberculosis is usually found to be 
present at autopsy, even though there may have been no pulmonary 
symptoms. Denime has reported a case of tuberculous laryngitis in a 
boy of four years, whose lungs were healthy, death resulting from tuber- 
culous meningitis. 

The symptoms are hoarseness, aphonia, laryngeal cough, and muco- 
purulent, sometimes bloody, expectoration. The sputum may contain 
tubercle bacilli. With the laryngoscope tuberculous deposits may be 
seen, but more frequently tuberculous ulceration of the mucous mem- 
brane. In children this is usually superficial, the deep destructive ulcera- 
tion seen in adults being very rare. 

It is to be differentiated from syphilis chiefly by the general symp- 
toms, as the laryngoscopy appearances may be very similar. The treat- 
ment consists in keeping the ulcers as clean as possible by the use of 
sprays and the local application of astringent powders, like nitrate of 
silver and sulphate of zinc or iodoform. 

3. Syphilitic Laryngitis. — In the early stage of syphilis the larynx is 
often the seat of a catarrhal inflammation, which presents nothing espe- 
cially characteristic except its protracted course. The laryngitis of late 
hereditary syphilis is quite rare, and is liable to be overlooked because 
of the difficulties in the way of a thorough examination, and because the 
disease is usually painless. 

Strauss has collected fourteen cases between the ages of three and 
fifteen years, and added three of his own. He states that deep-seated 
processes are much more rare than among adults. The parts most fre- 
quently affected are, first, the epiglottis: secondly, the aryteno-epiglottic 
folds; thirdly, the posterior laryngeal wall. The epiglottis was involved 
in twelve of fourteen cases. Usually there was only perichondritis: in 



470 DISEASES ov THE RESPIRATORY SYSTEM. 

the more severe cases there was partial or complete destruction of the 
cartilage. In four rases papillomatous masses were seen. In five cases 
the process extended from the epiglottis to the epiglottic folds of one 
or both sides. In several instances the superior vocal cords were thick- 
ened from hyperplasia, and occasionally small tumours were formed. 
In only one case was there ulceration of these folds. Changes in the 
vocal cords and the arytenoid cartilages were rare, occurring only with 
extensive inflammation. The symptoms are those of chronic laryngitis: 
hoarseness, sometimes aphonia, and in a few cases chronic laryngeal 
stenosis. The diagnosis can he made only by means of the laryngoscope. 
In most of the cases there are present ulcerations of the palate or uvula, 
or scars from previous ulcers; sometimes the disease extends into the 
nose. Serious symptoms often result when to old syphilitic lesions there 
is added acute laryngitis or oedema. 

In addition to the usual constitutional remedies for syphilis, and 
to the means ordinarily employed for the relief of chronic laryngitis, 
intubation may be required in these cases for the relief of laryngeal 
stenosis. Nowhere are its advantages over tracheotomy more striking 
than here. The tube must usually be worn for many months. 

NEW GROWTHS. 

New growths of the larynx are not very rare in children. Excluding 
the granulations which follow the use of the tracheal canula, the only 
one that is likely to be met with is papilloma. This may occur even in 
infancy. According to Bauchfuss, the majority of the cases begin dur- 
ing the first year. Boys are more frequently affected than girls. 

The symptoms depend upon the size and location of the tumour. The 
earlier manifestations are usually ascribed to chronic laryngitis. There 
is hoarseness, sometimes loss of voice, and a paroxysmal cough; later, 
dyspnoea develops which often increases by parox} T sms. The symptoms 
are slowly progressive, and it may be several months before they are suf- 
ficiently severe to attract special attention. A positive diagnosis is made 
only by the laryngoscope. There is seen a whitish granular tumour, 
sometimes pedunculated, sometimes with a broad base, attached to any 
part of the lar} r nx. 

The treatment of these cases belongs to the specialist. Small pedun- 
culated growths may be removed through the mouth by means of the 
forceps or snare. Larger ones require tracheotomy or thyrotomy. The 
prognosis after removal is unfavourable, on account of the likelihood of 
recurrence and the danger of broncho-pneumonia. Papillomatous tu- 
mours will sometimes disappear entirely if complete rest for the larynx 
is secured by means of tracheotomy ; but the tube must be worn for from 
six months to a year. 



FOREIGN BODIES IN THE LARYNX \M> BRONCHI. 471 



FOREIGN BODIES IN THE LARYNX AND BRONCHI. 

The aspiration of foreign substances into the larynx is not an un- 
common accident in children. It usually happens from an attempt to 
cough, laugh, or cry while the child has something in his mouth. If 
the body is sharp and irregular, like a pin, the shell of a nut, or a frag- 
ment of bone, it is liable to become impacted in the larynx. If smooth, 
like a pea or a bead, it is usually drawn into one of the bronchi, generally 
the right. 

When the body enters the larynx there is immediately excited a 
violent paroxysmal cough, with dyspnoea amounting almost to suffoca- 
tion. Often the body is dislodged by this initial attack of coughing. 
If it becomes impacted in the larynx, it may cause sudden death by 
occluding the glottis ; elsewhere it may excite acute laryngitis, usually of 
considerable severity. 

The impaction of a foreign body in one of the primary bronchi, or 
one of the lobar divisions, is indicated by cough and a severe localised 
pain in the chest. There may be expectoration of blood. On auscultat- 
ing the chest, there is found an absence of respiratory murmur over one 
lung or one lobe, according to the situation of the foreign body. Percus- 
sion gives marked dulness, the signs thus suggesting pleural effusion ; or 
there may be increased resonance, which may even be tympanitic, owing 
to the emphysema which rapidly develops. If the foreign body remains 
impacted in one of the bronchi, it usually excites a localised inflamma- 
tion, which extends to the surrounding lung and may terminate in the 
formation of an abscess. This may result fatally, or there may follow 
a prolonged illness, with hectic symptoms resembling pulmonary tuber- 
culosis; and finally, after weeks or months, the foreign body may be 
expelled by an attack of coughing, and the patient recover completely. 

The diagnosis of a foreign body in the larynx is made by the sudden- 
ness of the attack and the violence of the early symptoms. In older chil- 
dren the body may be seen with the laryngoscope, but in young children 
this is very difficult. The position of a metallic or solid body may be 
revealed by the X-ray. The prognosis is always doubtful, and depends 
upon the nature of the foreign body and the point at which it has been 
arrested. The usual cause of death either with or without operation is 
broncho-pneumonia. 

The first thing to he tried is inversion of the patient. By this 
means, assisted by the cough, the foreign body is not infrequently ex- 
pelled, even though it has passed below the larynx. The symptoms of 
laryngeal obstruction may call for immediate tracheotomy or laryn- 
gotomy, intubation not being applicable to these rases. If, after trache- 
otomy, the foreign body can he located in the larynx, hut can net 
be extracted through the tracheal wound, the thyroid cartilage should 



172 DISEASES ov THE RESPIRATORY SYSTEM. 

be divided in the median line. The removal of a foreign body from the 
bronchi or the trachea] bifurcation should be attempted only by a skilled 
Burgeon. 

CHAPTEK III. 

DISEASES OF THE LUNGS. 

THE PECULIARITIES OF THE LUNGS IN INFANCY AND EARLY 

CHILDHOOD. 

Thorax. — The general shape of the thorax is somewhat cylindrical, 
the conical or dome-shape of the adult thorax not being attained until 
puberty. The antero-posterior and the transverse diameters are nearly 
equal in the newly born, but after the third year the transverse diameter 
is always greater, the difference increasing steadily up to adult life. On 
account of the shape of the chest, the lungs are situated rather more 
posteriorly in the infant than in the adult. 

The thoracic walls are very elastic and yielding, owing to the carti- 
laginous condition of a large part of the framework. They are relatively 
thinner than in the adult, chiefly from the imperfect development of the 
thoracic muscles. The greater part of the thickness of the thoracic walls 
is due to the deposit of fat, generally abundant in well-nourished in- 
fants; but where the fat is scanty the walls are extremely thin. The 
capacity of the thorax is considerably encroached upon by the high posi- 
tion of the diaphragm, the large size of the thymus gland, and the fre- 
quent distention of the stomach and intestines. 

Respiration. — According to Uffelmann, the rapidity of respiration 
during sleep at the different ages is as follows : 

At birth 35 per minute. 

At the end of the first year 27 " " 

At two years 25 " " 

At six years 22 " " 

At twelve years 20 " " 

During waking hours this rate is very materially increased, and from 
comparatively slight disturbance it may be nearly twice as rapid. 

The type of respiration in infants is diaphragmatic, and it continues 
to be chiefly so until after the seventh year, when the costal element 
gradually becomes more and more prominent. The rhythm of respira- 
tion is easily disturbed. In very young infants the regular rhythm is 
seen only in sleep. The lungs do not always expand equally; at certain 
times and in certain positions respiration may be carried on for a few 
moments almost entirely with one lung. For some moments it may be 
very superficial, and then quite deep. The length of the interval between 
inspiration and expiration varies much at different times. Regular 



THE LUNGS IN INFANCY AND EARLY CHILDHOOD. 473 

rhythmical respiration is not fully established before the end of the sec- 
ond year. After this time disturbances of rhythm are due chiefly to pul- 
monary or cerebral disease; but in infancy quite marked irregularity 
may have little or no significance. It is very common in all asthenic 
conditions. 

Structure. — As compared with the adult, the trachea of the young 
child is larger; the bronchi are larger, more numerous, and occupy a 
greater space ; the air cells are much smaller and occupy less space ; and 
the interstitial tissue is much more abundant. 

Physical Examination. — This requires tact and time, but yields re- 
sults which are quite as satisfactory as in adults. It should be under- 
taken only in a room having a temperature of about 72° F., or before 
an open fire. 

Inspection. — This should be made with the chest bare. There should 
be noted, the shape of the chest, the presence of deformities from rickets, 
the want of symmetry in the two sides, bulging of the intercostal spaces, 
whether the two lungs expand equally or not, also variations in rhythm, 
and the presence and extent of any recession of the soft parts or bony 
walls as an indication of obstructive dyspnoea. 

Palpation. — This also should be made upon *the bare skin, always 
with the hand well warmed. Although we can not get the fremitus of 
the ordinary voice, we can get that of the cry. This is usually more 
intense than in adults, on account of the thinness of the chest walls. We 
frequently get a bronchial fremitus — a vibration produced by mucus in 
the tubes. The position of the apex beat of the heart should be deter- 
mined, it being remembered that in infancy this is normally in the 
mammary line, or just outside of it, and usually in the fourth intercostal 
space. 

Percussion. — For the examination of the back, the child may be laid 
face downward upon the nurse's lap, or be seated upon her arm. For 
the front and the lateral regions of the chest, the child is most con- 
veniently placed upon his side across a hard pillow. The percussion blow 
must be light, either with a single finger or a small percussion hammer, 
using a finger of the opposite hand as a pleximeter. Percussion should 
be made both during inspiration and expiration. The normal percus- 
sion note is somewhat tympanitic, this being due to the relatively large 
bronchi and the thin chest walls. This note is exaggerated in the inter- 
scapular region and beneath the clavicle, especially upon the right side. 
Here cracked-pot resonance may be obtained even in health. In early 
infancy the thymus gives dulness over the sternum as low as the third 
rib, sometimes even below this point, this gradually diminishing as age 
advances. 

Auscultation. — This may be practised with the naked ear or with the 
stethoscope. A stethoscope is absolutely necessary for a thorough exam- 



474 DISEASES OF THE RESPIRATORY SYSTEM. 

mation of the apices of the Lungs in front and in the axillary regions. 
Most children are loss frightened by the instrumenl than by the head of 
the physician during anterior auscultation. The physician should always 

auscultate the posterior pari of the chest first, because lie is most likely 
to find Bigns of disease there, and also because this is not so apt to 
frighten the infant. Every part of the chest should, however, be thor- 
oughly auscultated, not omitting the high axillary regions. A con- 
venient position for posterior auscultation is to have the child held over 
the nurse's shoulder. 

The normal respiratory murmur of the infant is generally described 
as " puerile." In quality this has been likened to the bronchial breath- 
ing of the adult, but the resemblance is not a very close one. It is rude, 
rather loud, and seems very near the ear. Its peculiar character is due 
to the fact that the tracheal and bronchial sounds are more distinct, 
because not transmitted through so thick a layer of lung and chest wall. 
It is especially loud in the regions where the bronchi are superficial, as 
between the shoulder-blades and beneath the clavicles, particularly of 
-the right side. A careful comparison of the two sides of the chest will 
generally enable an observer to avoid errors. The irregularity of rhythm 
which occurs from slight causes should be remembered, and the infant's 
position changed several times during auscultation, to avoid the mis- 
take of attaching too much importance to a feeble respiratory murmur 
of one side. 

On account of the thinness of the chest walls, there is always great 
difficulty in distinguishing between rales produced in the bronchi and 
pleuritic friction sounds. Before drawing any inference from the auscul- 
tatory signs, both lungs must be examined for several minutes, changing 
the child's position, and often inducing a cry or compelling a deep inspi- 
ration by other means, in order to bring out signs which otherwise may 
be overlooked. As auscultation is extremely difficult or impossible in a 
crying infant, this part of the physical examination should be made first 
if the child is quiet, since upon it we must chiefly depend for diagnosis. 
Inspection and percussion can be deferred until later. 

Peculiarities in Disease. — There are several peculiarities connected 
with the respiratory organs in infancy and early childhood which must 
be constantly borne in mind in studying their diseases. The muscular 
development of the thoracic wall is feeble. The soft, yielding character 
of the thoracic framework causes the chest to sink in readily from at- 
mospheric pressure whenever there is obstructive dyspnoea. On account 
of the small size of the air vesicles, acute congestion may interfere 
with their function almost as eonipletely as does consolidation. Because 
of the delicate walls of the air vesicles, emphysema is readily produced 
in obstructive dyspnoea, but it is rarely permanent. There is a tendency 
to collapse, either on the part of lobules or groups of lobules, but very 



ACUTE CATARRHAL BRONCHITIS. 17.', 

rarely of an entire lobe. This is a much less importani factor in the 

production of symptoms in acute pulmonary disease than many writer- 
would lead us to suppose. The tendency of inflammation to spread from 
the large to the small bronchi is very much greater than in adults. In 
all forms of pulmonary disease the rapidity of respiration is much greater 
than in adults. Areas of consolidation often exist without appreciable 
changes in the percussion note, because they are superficial and are sur- 
rounded by healthy or emphysematous lung. Flatness should alwavs 
suggest the presence of fluid. Disease is often overlooked, from a failure 
to examine the whole chest. 

Probably the most common mistakes are to confound bronchial rales 
with friction sounds, exaggerated puerile breathing with bronchial breath- 
ing, and to overlook the existence of fluid because of the presence of 
bronchial breathing. 

ACUTE CATARRHAL BRONCHITIS. 

Acute catarrhal bronchitis is one of the most frequent conditions for 
which the physician is called upon to prescribe in children. It occurs at 
all ages, from early infancy up to puberty. Its frequency, however, 
diminishes steadily after the second year. The predisposition to acute 
bronchitis exists with the same constitutional conditions, and is acquired 
in the same manner as the predisposition to the acute catarrhal inflam- 
mations of the upper respiratory tract. (See Acute Rhino-Pharyngitis.) 
Bronchitis is very common in children who are suffering from rickets and 
malnutrition. It is much more frequent in the cold months, especially 
in the late winter and early spring, when there are sudden atmospheric 
changes and high winds. The presence of large tonsils and adenoid 
vegetations of the pharynx are important predisposing causes of bron- 
chitis. 

Bronchitis may be a primary or a secondary disease. The primary 
form is excited by cold, exposure with insufficient clothing in severe 
weather, wetting of the feet, or chilling of the surface in any manner. 
Under these conditions it may occur alone, or be associated with or 
preceded by acute catarrh of the nose, pharynx, or larynx. In rare cases 
it is caused by the inhalation of irritants. Bronchitis is an almost in- 
variable accompaniment of measles and influenza. It is very common 
in pertussis, in scarlet and typhoid fevers, and diphtheria, and may 
occur in any acute infectious disease; it also complicates pneumonia and 
pleurisy. The micro-organisms associated with bronchitis are chiefly 
the staphylococcus aureus and the pneumococcus, often in combination; 
next in importance are the streptococcus and, especially in protracted 
cases, the influenza bacillus. 

Lesions. — Acute catarrhal bronchitis is an inflammation of the mucous 
membrane of the bronchi. As a rule it is bilateral, both sides being 



476 DISEASES OF THE RESPIRATORY SYSTEM. 

involved in the same degree. Localised bronchitis is secondary to some 
other pathological process in the lungs, usually tuberculosis, old pleuritic 
adhesions, or pneumonia. In acute bronchitis only the larger tubes may 
be affected, this usually being complicated with inflammation of the 
trachea (ordinary tracheo-bronchitis) ; or, in addition, the process may 
extend to the medium-sized tubes (severe bronchitis) ; or, in infants 
especially, it may extend to the smallest tubes (capillary bronchitis). 
In the last-mentioned form there are invariably changes in the zones 
of air vesicles surrounding the bronchi, and these cases are therefore 
more properly classed as broncho-pneumonia. In the first form the in- 
flammation is superficial, and affects only the mucous membrane of the 
bronchi. In the second form it may involve the entire thickness of the 
bronchial wall, and in the third form it does so regularly. 

The pathological changes consist in congestion and swelling of the 
mucous membrane, desquamation of the epithelium, and an exudation of 
mucus and pus-cells. At autopsy the injection of the mucous membrane 
is usually distinct; pus and mucus line the walls of the larger bronchi, 
and by pressure ooze from the cut extremities of the smaller tubes. The 
chief lesion of the walls of the bronchi consists in an infiltration with 
leucocytes. In infants dying from bronchitis, the lungs are much more 
frequently emphysematous than collapsed. In fact the readiness with 
which emphysema occurs in bronchitis is one of its distinguishing feat- 
ures in infancy. However, this is rarely permanent but usually sub- 
sides rapidly after the acute attack is over. There is swelling of the 
lymph nodes at the root of the lungs, which in most of the acute cases 
is slight, but in protracted cases, and after recurring attacks, may be 
quite marked. 

Symptoms. — It is convenient to consider separately the symptoms in 
infants and in older children. 

The Bronchitis of Infants. — 1. The Mild Form (Bronchitis of 
the Larger Tubes). — The onset is generally gradual, and the symptoms 
of bronchitis may be preceded by those of catarrh of the nose, pharynx, 
or larynx. The change in the character of the cough, the slightly ac- 
celerated breathing, and a further rise in temperature, indicate an ex- 
tension to the bronchi. The cough may be constant and severe, or very 
slight. There is no expectoration. The secretions are usually coughed 
up into the mouth or pharynx, and swallowed. This sometimes excites 
vomiting. At other times the mucus is coughed only into the trachea 
or larynx, and aspirated again into the lungs. The respirations are from 
forty to fifty a minute, and often accompanied by a rattling sound, due 
to mucus in the large bronchi or trachea. The general symptoms are 
not severe, and unless the infant is very young or very delicate no ap- 
prehension need be felt as to the outcome. The temperature is generally 
from 100° to 102° F. for two or three days, then below 100° F. A mod- 



ACUTE CATARRHAL BRONCHITIS. 477 

erate amount of restlessness dependent upon the severity of the cough, 
anorexia, and sometimes vomiting and diarrhoea, are usually present. 

The physical signs in the first stage are dry, sonorous rales over the 
whole chest. A little later these give place to coarse mucous rales heard 
everywhere, but especially distinct between the scapulas and in the infra- 
clavicular regions. On palpation there is usually a marked bronchial 
fremitus. Often there is not enough dyspnoea to cause recession of the 
soft parts of the chest. Unless the disease extends to the smaller bronchi 
and the air vesicles, the illness usually lasts about a week. Coarse rales 
in the chest may remain for some time after the symptoms have subsided. 
Relapses are exceedingly common. In a delicate or rachitic child, or in 
one whose surroundings are bad, one attack is likely to be followed by a 
succession of others, so that the child may not be really well until warm 
weather comes. The general health may suffer from the prolonged con- 
finement to the house, although the patient may never have been seri- 
ously ill. 

2. The Severe Form (Bronchitis of the Smaller Tubes). — This dif- 
fers from the preceding variety mainly in the greater severity of all its 
symptoms. The onset may be like that just described, the severe symp- 
toms not appearing until the patient has been sick two or three days, 
or they may be severe from the outset. If the latter, it is indistinguish- 
able from broncho-pneumonia. There is cough, dyspnoea, accelerated 
breathing, fever, and moderate, sometimes severe, prostration. The 
cough is tighter, and more frequently of a short, teasing character than 
severe and paroxysmal. There is difficulty in nursing. Dyspnoea may 
be quite marked and is. shown by the active dilatation of the alae nasi and 
the recession of all the soft parts of the chest on inspiration. The 
respirations, as a rule, are from 50 to 80 a minute. The temperature 
for the first day or two is usually 101° or 102° ¥., but it may be 103° 
or 104° F. So high a temperature does not continue unless pneumonia 
develops. The prostration is in most cases more closely related to the 
dyspnoea and the rapidity of respiration than to the temperature. Often 
there is slight cyanosis. 

In the beginning the chest is filled with sibilant and sonorous rales. 
In twelve or twenty-four hours these are wholly or in part replaced by 
moist rales — coarse or fine, according as they are produced in the large 
or medium-sized tubes. The rales are always best heard behind, but they 
are present all over the chest. The signs are often precisely like those of 
an acute asthma. This prominence of the spasmodic or asthmatic ele- 
ment in bronchitis is characteristic of infancy and early childhood. The 
respiratory murmur is feeble; the resonance on percussion is normal or 
slightly exaggerated. As the case progresses toward recovery, the finer 
rales are the first to disappear. After the acute stage has passed the 
loud wheezing sounds sometimes persist for two or three weeks. 



478 DISEASES OF THE RESPIRATORY SYSTEM. 

At the onset of such a case it is impossible to say whether the disease 
will be limited to the medium-sized bronchi or will extend to the small- 
est bronchi and air vesicles. In young or very delicate infants, and dur- 
ing measles, it is very common for the disease to spread rapidly to the air 
vesicles. In other cases, usually in infants under six months old, there 
may develop attacks of respiratory failure or suffocation. These may 
occur in a severe case at any time, and, because of the infant's inability 
to empty the tubes of secretion, the dyspnoea steadily increases until the 
respiratory muscles are exhausted, the inspiratory force being too feeble 
to overcome the obstruction in the tubes. The symptoms which follow 
are usually ascribed to pulmonary collapse. I am, however, by no means 
certain that this is the correct explanation, for in autopsies made in such 
cases I have usually found the lungs to be the seat of acute emphysema. 
The clinical picture is a clear one. There is no disposition to cough or 
cry; the pulse is feeble; the respiration very rapid, superficial, often 
irregular; the skin cyanotic, and often clammy. Finally, there may be 
added to the others signs of carbonic-acid poisoning, dulness, apathy, 
and stupor. Such attacks may come on quite suddenly even in robust 
infants, and unless the treatment is energetic, even heroic, death often 
follows in a few hours, being frequently preceded by convulsions. 

The usual course of the disease in infants previously in good health 
is that the severe symptoms continue for two or three days only, after 
which the temperature falls to 100° or 100 . 5° F., and gradually becomes 
normal. The constitutional symptoms usually decline with the tempera- 
ture, and, except during the first thirty-six hours, they rarely give cause 
for anxiety. Recovery almost invariably occurs unless the disease ex- 
tends to the finer bronchi. 

Bronchitis is principally to be distinguished from broncho-pneumonia. 
The differential diagnosis is more fully considered under that disease. 
The most important points are that in pneumonia the temperature is 
higher and more prolonged, the prostration greater, the rales very often 
localised — being heard only behind, often over only one lung — the dura- 
tion is more protracted, and all the symptoms are more severe. In 
nearly all cases of severe bronchitis in young children some pneumonia 
is present. 

The Broncliitis of Older Children. — This is not nearly so serious 
as in infants, because the same danger does not exist of extension of the 
inflammation to the finer bronchi and air cells. 

1. The Mild Form. — This is very common. The constitutional symp- 
toms are slight, and often entirely absent after the first day. The patient 
is never sick enough to go to bed. The first symptoms are cough and 
soreness or a sense of oppression beneath the sternum. The cough is 
always worse at night. It is at first tight, hard, and racking ; later it is 
loose, and in children over five years old there is usually expectoration — 



ACUTE CATARRHAL BRONCHITIS. 479 

first of white, frothy mucus, but after a few clays it becomes more abun- 
dant, and of a yellow or yellowish-green colour, from the presence of pus. 
The physical signs are only coarse rales, at first dry, and later moist, but 
heard over both sides of the chest, in front and behind. There may be 
some disturbance of digestion, anorexia, constipation, or diarrhoea. The 
usual duration of the attack is from one to two weeks. If the patient is 
not kept indoors the disease may pass into a subacute form, lasting for 
several weeks as a protracted " winter cough," but without any other im- 
portant symptoms. 

Such prolonged or recurring attacks of bronchitis of a subacute form 
should suggest influenza or tuberculosis. A positive cutaneous tuberculin 
reaction renders tuberculosis probable. A careful search for bacilli in 
the sputum should then be made. Although they may not be found at 
first, repeated examinations will usually disclose them. Influenza can 
be determined only by sputum cultures. 

2. The Severe Form. — The onset is abrupt, with fever, chill, pains in 
the back, headache, cough, and sometimes pain in the chest. There is a 
feeling of tightness or constriction beneath the sternum. The onset 
resembles that of pneumonia, except that the symptoms are less severe. 
The temperature for the first two or three days ranges between 100° and 
103° F. It is generally highest in the first twenty-four hours. The 
cough resembles that of the mild form, but it is usually more severe. 
The expectoration is more profuse, and occasionally, in the early stage, it 
may be streaked with blood. 

The coarse rales of the mild form are present, and in addition there 
are finer rales — at first dry, and later moist — heard all over the chest. 
Frequently, wheezing rales are heard on expiration. The duration of the 
attack is ordinarily from two to three weeks, the patient being sick 
enough to be confined to bed for three or four days only. There is fre- 
quently a cough for some time after all physical signs have disappeared. 
Relapses are easity excited by any indiscretion before the patient has 
quite recovered. 

The prognosis in the primary cases is good, such almost invariably 
terminating in recovery, and very exceptionally passing into broncho- 
pneumonia; but this not infrequently happens when the attack compli- 
cates measles or pertussis. 

Treatment of Bronchitis. — To remove the predisposition to bronchitis 
the same means should be employed as those mentioned in Acute Rhino- 
Pharyngitis. Children with tuberculous antecedents, and those who 
are especially prone to pulmonary disease, should, if possible, spend the 
winter in a warm climate. The sleeping apartments of susceptible in- 
fants should not be too cold— never below 60° F.— but they should be 
well ventilated. It is important in infants and young children that mild 
attacks of bronchitis should not be neglected. 



480 DISEASES OF THE RESPIRATORY SYSTEM. 

Every young child who has an acute catarrh of the nose, pharynx, lar- 
ynx, or bronchi should be kept indoors. In every such catarrh accompa- 
nied by fever the child should be kept in bed while the fever lasts, even if 
the temperature does not go above 100.5° F., and is accompanied by no 
other constitutional symptoms. A very large number of the cases will 
recover promptly when no other treatment is employed than to keep the 
child in bed. Fresh air is indispensable. But the advantages of cold air 
have not yet been demonstrated. According to my experience, the wide- 
open windows have no place in the treatment of acute bronchitis in in- 
fants or young children in the winter and spring season. The tempera- 
ture of the room should be about 70° F. The room should be well 
ventilated and frequently aired, the child meanwhile being removed to 
another room. There is a great advantage in changing the child's posi- 
tion in the crib and from the crib to the nurse's arms. Careful attention 
should be given to feeding and to the condition of the bowels. A cathar- 
tic, preferably castor oil, should be administered at the outset. 

Poultices are objectionable and should not be employed. The oiled 
silk jacket is sometimes useful. Counter-irritation is very valuable. In 
infants, the best results are obtained by the frequent use of a mustard 
paste (see chapter on General Therapeutics). The paste may be re- 
peated, according to indications, from two to five times a day. If prop- 
erly used, it will not injure the skin. 

Inhalations may, in the great majority of cases, take the place of the 
administration of drugs by the mouth, a very great advantage in infants. 
They may be used by means of the croup kettle, the child always being 
placed in a tent. In the early part of the disease relaxing inhalations, 
like simple aqueous vapour or lime-water, may be used. Later turpen- 
tine, creosote, benzoin, terebene, or eucalyptol may be added. Of these, 
creosote has given me the most satisfaction. Inhalations are to be used 
for ten or fifteen minutes from four to twelve times a day. 

In infancy, expectorants may advantageously be dispensed with. 
For older children, antimony and ipecac may be used in the first stage. 
When the secretion is more abundant, creosote, turpentine, or terebene 
may be given. Small, frequently repeated doses usually give the best 
results. Opium should be given cautiously to infants. The dry, har- 
assing cough of the early stage sometimes yields to nothing so quickly 
as to small doses of Dover's powder (e. g., one-tenth of a grain every 
two hours to a child of one year). The use of emetics to get rid of 
bronchial secretion is not to be advised. Stimulants are not required 
in most of the cases. The indications for them are the same as in pneu- 
monia. When there is much dyspnoea of the asthmatic type, nothing 
works as well as adrenalin. It should be given hypodermically ; the dose 
is two to five minims of the 1-1,000 solution. The effects are almost im- 
mediate, but often only transient. 



FIBRINOUS BRONCHITIS. 481 

Should attacks of suffocation and respiratory failure occur in infants, 
the indications are to excite respiratory movements and to get as much 
blood as possible to the surface and the extremities. Flagellation or 
spanking and the use, alternately, of hot and cold douches to the chest 
will sometimes induce the deep respiratory efforts desired. Other useful 
measures are the hot mustard bath and the mustard pack applied to the 
entire body. Probably the most effective of all remedies is dry cupping. 
The chest should be cupped front and back for five or ten minutes every 
few hours. Oxygen should be administered. As these symptoms are 
liable to recur every few hours for a day or two, a repetition of the 
treatment may be needed. For such patients cold air is injurious. They 
should be kept in a room with a temperature of 70° to 72° F. 

In the non-febrile cases in older children, confinement in bed is un- 
necessary, but they should be kept indoors. In the early stage, with 
hard, dry cough, one of the best remedies is brown mixture (the mis- 
tura glycyrrhizse composita of the U. S. P.). It will be found advan- 
tageous in most cases to have the formula made up with one-half the 
usual amount of opium. When the cough is especially hard and dry, 
a single inhalation may be used at bedtime. In the second stage, muriate 
of ammonia may be added to the brown mixture; or terebene, two or 
three drops upon sugar, may be given four or five times a day, and in- 
halations should be used several times a day. 

In the more severe cases the patients should be kept in bed and coun- 
ter-irritation to the chest employed. For the general discomfort, pain, 
headache, etc., nothing is better than phenacetine and Dover's powder 
(two grains of the former to one-half grain of the latter to a child of 
five years), repeated every three to six hours. All patients should be 
kept in bed as long as the temperature is above normal. 

After all physical signs and constitutional symptoms have disap- 
peared, a cough continues sometimes for weeks. Expectoration is scanty, 
or is wanting altogether; the cough is hard, dry, often paroxysmal, and 
in some cases occurs at night only. For this condition the best reme- 
dies are cod-liver oil and creosote. When these measures are not effect- 
ive, a change of climate should be advised. 



FIBRINOUS BRONCHITIS (Bronchial Croup). 

Fibrinous bronchitis is seen in diphtheria, usually as an extension 
from the larynx or trachea. There is, however, another form of bron- 
chitis attended by a fibrinous exudate, which occurs as a primary disease. 
This is very rare in children. Weil has, however, collected twenty cases 
of the primary form. The etiology is obscure. It is seen at all ages, 
from infancy up to puberty, and it may be either acute or chronic. From 
the cases thus far reported it would appear that the acute form is rela- 



482 DISEASES OF THE RESPIRATORY SYSTEM. 

tively more common in children than in adults. The disease may be 
confined to certain branches of the bronchial tree, or it may affect all the 
bronchi, even to the minute subdivisions. The fibrinous membrane is 
found loose in the tubes or adherent. There are generally associated 
other pulmonary changes, such as emphysema, atelectasis or broncho- 
pneumonia. 

The acute form somewhat resembles ordinary catarrhal bronchitis. 
The diagnostic features are, the severity of the dyspnoea and the expecto- 
ration of tube casts from the larger bronchi, or elongated cylinders from 
the smaller ones, the former resembling macaroni, the latter, vermicelli. 
The expectorated masses are often in balls or plugs, and their peculiar 
character is not recognised until they are placed in water. The casts 
are dissolved by alkalies, especially by lime-water. After the expulsion of 
a large cast, improvement in all the symptoms occurs. They, however, 
return as the exudate reappears. The ordinary duration of acute cases 
is from one to three weeks. 

In the chronic form there are no constitutional symptoms, but only 
dyspnoea and cough, often recurring in paroxysms, with the expectora- 
tion of fibrinous casts. The patient may have these attacks at intervals 
of a few days or weeks, extending over a period of months, or even years. 
There are no characteristic physical signs. The diagnosis rests upon the 
peculiar character of the expectoration. The prognosis in acute cases is 
unfavourable, the mortality being 75 per cent (Weil). Chronic cases are 
not dangerous to life. 

Treatment. — This is quite unsatisfactory. To loosen the membrane 
and facilitate its expulsion, the most efficient means are inhalations of 
the vapour of lime-water and the internal administration of pilocarpine. 
Occasionally emetics are of value. Improvement in some of the chronic 
cases has resulted from the use of iodide of potassium. 

CHRONIC BRONCHITIS. 

Chronic bronchitis is not a very common disease in children, partic- 
ularly in young children, one reason being that chronic emphysema, so 
frequently an associated condition in adults, is rather rare in early life. 
Chronic bronchitis always accompanies chronic pulmonary tuberculosis 
and chronic interstitial pneumonia, with or without the occurrence of 
bronchiectasis. It is seen in chronic cardiac disease, especially with 
lesions of the mitral valve. It may occur as a late symptom of hereditary 
syphilis. Excluding the varieties mentioned, it usually follows attacks 
of acute bronchitis, the process becoming chronic because of the patient's 
constitutional condition or his unhygienic surroundings. The acute at- 
tack may be primary, but it often follows measles and whooping-cough. 
Rickets, general malnutrition, and the lymphatic diathesis are the con- 



REFLEX COUGH— NERVOUS COUGH. 483 

stitutional conditions in which acute bronchitis is most likely to pass 
into the chronic form. Deformities of the chest, the result either of 
rickets or of Pott's disease, are occasionally a cause. 

Symptoms. — The only constant symptom is cough, which is per- 
sistent, obstinate, and nearly always worse at night or early in the morn- 
ing. It often occurs in paroxysms strongly suggestive of pertussis. Ex- 
pectoration is not generally abundant, but in older children it is usually 
present, and in a few cases it is profuse. A copious morning expectora- 
tion of foetid pus or muco-pus indicates bronchiectasis. There is no 
fever, little or no dyspnoea, and although the patients are thin, they are 
not emaciated, and in many cases the general health is not much affected. 
There may be coarse mucous rales, or no physical signs whatever. The 
duration of the disease is indefinite, depending upon the cause. All 
these patients are better in summer than in winter, and suffer fre- 
quently from exacerbations of acute or subacute bronchitis. 

The diagnosis is to be made mainly from pertussis and tuberculosis. 
From mild attacks of pertussis the diagnosis may be impossible except by 
the course of the disease. Tuberculosis may be suspected if the thermom- 
eter shows regularly a slight evening rise of temperature, if there is 
much anaemia, and steady loss of flesh. It may, however, be present 
without any of these symptoms. A positive cutaneous reaction is sug- 
gestive, but a certain diagnosis can be made only by the discovery of 
tubercle bacilli in the sputum. 

Treatment. — The first indication is to treat the primary disease. In 
cardiac cases digitalis is the best remedy, and all sedatives are to be 
avoided. Attention should be directed to the general condition — rickets 
and malnutrition each receiving its appropriate treatment. In most 
cases a general tonic plan of treatment is best, particularly the con- 
tinuous use of cod-liver oil. In many cases a change of climate is the 
only thing which is really curative. For the relief of cough, opiates are 
to be avoided as much as possible. The main reliance should be upon 
potassium iodide, creosote, and terebene, the last two being given both by 
mouth and by inhalation. 



REFLEX COUGH— NERVOUS COUGH. 

Strictly speaking, all cough is reflex and of nervous origin. The term 
" reflex cough " is, however, commonly used to denote that which occurs 
without any evidence of disease in the larynx, trachea, bronchi, lungs, or 
pleura. On account of the close connection through the vagus and its 
branches between the mouth, ear, throat, stomach, and thoracic organs, 
it is possible for cough to be produced by many forms of irritation in 
these organs or cavities. Clinically, the following varieties of nervous 
cough are observed: 



484 DISEASES OF THE RESPIRATORY SYSTEM. 

1. That dependent upon rhino-pharyngeal irritation. This is the 
most frequent form, and is sometimes caused by an elongated uvula, but 
is usually due to adenoid growths of the pharynx, though enlargement 
of all the lymphoid tissues of the neighbourhood no doubt have a part. 
The cough is generally excited by an accumulation of mucus in the 
posterior pharynx, and is dry, tickling, or hemming in character. It 
occurs chiefly at night, and in some patients only then; it may begin 
soon after the child falls asleep and continue the greater part of the 
night, often for months, especially in the cold season. Formerly, such 
coughs were often attributed to disorders of digestion, to dentition, to 
otitis, etc. 

2. Cardiac cough. This is usually associated with mitral disease, 
and is due to pulmonary congestion. The cough may be dry and hard, 
but when the congestion is severe there may be frothy and blood-streaked 
expectoration. 

3. A variety which occurs usually about the time of puberty, and 
is often associated with anaemia, chorea, or other nervous conditions. It 
is a short, hacking, or teasing cough, sometimes very distressing, and it 
seems to be a manifestation of extreme nervous irritability. 

4. A periodical night cough, which is generally ascribed to irrita- 
tion of the vagus or its branches by enlarged, sometimes caseous, lymph 
nodes of the tracheo-bronchial group. This often occurs in severe 
paroxysms, the character of which is very much like pertussis. The 
attacks are apt to come on about the middle of the night and last for 
several hours. Vomiting is rare. The cough may recur regularly every 
night for months. On account of the loss of sleep the patient's general 
health may be considerably undermined. 

5. A very similar cough may occur in connection with abscesses in 
the posterior mediastinum, due to Pott's disease. 

Symptoms and Diagnosis. — These cases are not common in infants, 
but are quite frequent in older children. In nearly all the varieties 
the cough is worse at night, and in many it may be confined to that 
time. The influence of habit is often seen, the attacks coming on regu- 
larly at certain periods. The general health may not be affected, except 
from the disturbance of sleep. The diagnosis between the different 
forms is often very difficult. The precise cause in a given case is dis- 
covered only by a careful examination of the ear, nose, pharjmx, heart, 
stomach, and lungs, and by a consideration of the patient's general con- 
dition. The symptoms by which a diagnosis of enlarged or tuberculous 
bronchial glands is made are discussed in another chapter. Symptoms 
in some respects similar to these may exist with abscesses from Pott's 
disease. 

Treatment. — Opium and expectorants are not indicated, and inhala- 
tions are of little value. The only successful treatment is that which is 



ASTHMA. 485 

directed to the cause of the disease. Tf no cause can be found, and the 
cough appears to be of purely nervous origin, the best results follow the 
use of the bromides or the administration of antipyrine at bed ti inc. 



ASTHMA. 

Asthma may be denned as a vaso-motor neurosis of the respiratory 
tract. It is characterised by attacks of severe spasmodic dyspnoea, which 
may be preceded, accompanied, or followed by a bronchitis of greater 
or less severity. In infanc}', the association of asthma with bronchitis is 
a very close one, and the cases present quite a different clinical picture 
from the disease as seen in older children, which differs in no essential 
points from the asthma of adults. 

Writers differ very much in their statements regarding the fre- 
quency of asthma in early life, mainly because of a want of agreement in 
regard to what shall be included under this term. The asthmatic attacks 
of infants are considered by some as a stage of bronchitis, by others as 
distinct from that disease. Typical attacks resembling those of adult life 
are rare in children, and extremely so before the seventh year. How- 
ever, of 225 cases of asthma reported by Hyde Salter, the disease began 
before the tenth year in nearly one-third the number. 

Etiology. — The general or constitutional causes are the same in chil- 
dren as in adults. Asthma is often hereditary. It occurs especially in 
children whose antecedents have suffered from gout or from various neu- 
roses. It often occurs in children who in infancy have suffered from 
eczema. The local cause may be any form of irritation in the nose or 
pharynx — hypertrophic rhinitis, adenoid growths of the pharynx, hyper- 
trophied tonsils, or elongated uvula — or in the bronchial mucous mem- 
brane, as a result of previous attacks of acute bronchitis. It is probable 
that it may also be caused by the irritation of enlarged bronchial glands. 
In susceptible persons a paroxysm may be excited by high winds, by cold 
and damp air, indigestion, constipation, or the inhalation of various irri- 
tating substances, such as dust, the pollen of certain plants, also from 
contact with horses, cats, and other animals. First attacks of asthma 
in children are apt to follow bronchitis. 

Symptoms. — Four quite distinct clinical types of asthma are seen in 
children: (1) Cases which in their onset simulate attacks of bronchitis. 
(2) Those in which asthmatic symptoms follow an attack of bronchitis, 
continuing for weeks or months, but not necessarily recurring. (3) 
Hay fever, or the periodical form which occurs every summer, (-i) 
That which resembles the ordinary adult asthma, with the nervous 
element predominating. The prominence of the catarrhal symptoms is 
characteristic of all forms of asthma in children, the first two varieties 
mentioned being peculiar to early life. 



486 DISEASES OF THE RESPIRATORY SYSTEM. 

At fads Resembling Acute Bronchitis. — These cases are rare, but 
may be seen even in infants. The onset is sudden, with moderate fever, 
incessant cough, severe dyspnoea, and sometimes symptoms of suffocation 
■cyanosis, prostration, and cold extremities. The chest is filled with 
sonorous, sibilant, and soon with subcrepitant rales. Instead of running 
the usual course of bronchitis of the finer tubes, the symptoms may pass 
away very rapidly, and in forty-eight, sometimes in twenty-four, hours 
the patient may be quite well. It is only by the course of the disease 
and by recurring attacks that their true nature can be recognised. In 
infants this form of asthma may be fatal. 

Cases following Attacks of Bronchitis — Catarrhal Asthma. — This 
form is not uncommon, though it is frequently designated by some other 
term than asthma — sometimes as spasmodic bronchitis, or catarrhal 
spasm of the bronchi. The symptoms are, however, indistinguishable 
from asthma, and they evidently belong in the same category. This 
form is usually seen in infants, being rare after the third year. Many 
of the patients are rachitic ; others have large tonsils, or adenoid growths 
of the pharynx; while in still others there is every reason to suspect 
the presence of large bronchial glands. Usually there is nothing pecu- 
liar about the antecedent bronchitis; in most cases it is not espe- 
cially severe, and is limited to the larger tubes. The febrile symptoms 
subside in a few days, but the cough continues, as do also the dyspnoea 
and wheezing. When the symptoms are fairly established they are 
very uniform and characteristic. The respiration is accelerated, usu- 
ally to 50 or 60, sometimes to 70 or 80, a minute. The temperature 
from time to time may be very slightly elevated, or it may remain 
normal. The respiration is noisy, laboured, and accompanied by dis- 
tinct wheezing. 

On auscultation, there is prolonged expiration accompanied by loud, 
wheezing and sonorous, or sibilant rales, and occasionally coarse moist 
rales are heard. In cases which have lasted some time a moderate amount 
of emphysema can be inferred from the prominence of the infra-clavicular 
regions, and exaggerated resonance over the chest in front and the 
depression of the bases posteriorly. 

These symptoms and signs may continue for three or four weeks only, 
and gradually wear off, or they may last as many months — if they begin 
in the winter or spring, often continuing until the middle of the summer. 
While they are constantly present, they vary in intensity from time to 
time, being usually much worse at night. The symptoms are always 
increased by exposure to a cold, damp atmosphere, by any fresh acces- 
sion of bronchitis, and often by trivial digestive disturbances. The usual 
duration of the cases I have seen has been from two to six weeks. The 
cough is not usually severe, and expectoration in most cases is absent. 
The general health is often but little affected. With recovery from the 



ASTHMA. 487 

asthmatic symptoms the emphysema usually disappears gradually, al- 
though I have seen one severe case in which it persisted. 

What proportion of these children afterward develop ordinary asthma, 
I am unable from personal experience to say. Some undoubtedly do, 
but in others which I have been able to follow, recovery has seemed to 
be permanent. This would appear more likely in those cases closely 
associated with rickets, or with other causes which disappear spontane- 
ously with time or as a result of treatment. 

Hay Fever. — This is very rare before the seventh, and but few well- 
marked cases are seen before the tenth year. In its clinical aspects it 
does not differ essentially from the disease as seen in adults, except pos- 
sibly by the greater prominence of the bronchial catarrh. 

Ordinary Attacks of the Adult Type. — These usually occur at inter- 
vals of a few weeks or months, depending upon the nature of the excit- 
ing cause, The beginning is usually at night, with dyspnoea, a short, dry 
cough, and loud, wheezing respiration. Deep recession of the soft parts 
of the chest is seen, as in laryngeal stenosis. There is prolonged expira- 
tion, accompanied by loud, sonorous, sibilant and wheezing rales, and 
the vesicular murmur is very feeble. Later, moist rales may be 
heard. After many attacks emphysema is present. This occurs more 
rapidly than in adults, and may be extreme, giving rise in marked cases 
to serious thoracic deformity. On account of the loss of sleep and 
interference with nutrition, the general health may become seriously 
impaired. 

Diagnosis. — Typical attacks of asthma are easily recognised. Some 
of the catarrhal forms seen in infancy, however, present some difficulty, 
and a positive diagnosis may be impossible except by the progress of the 
case. The blood picture in asthma is characteristic and of much value 
in diagnosis. The important thing is the presence of a large number of 
eosinophile cells. They may form as high as 15 to 20 per cent of the 
leucocytes. In a series of cases examined in my clinic by Wile, the 
average was 10.7 per cent; the highest being 26 per cent. The eosin- 
ophilia is greatest at the height of the attack. The blood examination 
serves to differentiate asthma from simple bronchitis and from tuber- 
culosis. The existence of marked eosinophilia definitely establishes the 
asthmatic character of some of these attacks in infancy. 

Prognosis. — This is best in the cases of catarrhal asthma in infants, 
.and in older patients when it depends upon some local cause which can 
be removed, as when the disease is due to reflex nasal or pharyngeal 
irritation. In the majority of other cases, asthma is likely to become 
chronic unless the child is removed to some climate in which the attacks 
do not occur. The younger the child, the shorter the duration of the 
disease, and the less marked the hereditary tendency, the better the 
prognosis. 



488 DISEASES OF THE RESPIRATOR? SYSTEM. 

Treatment. — The Qose and the rhino-pharynx should be carefully 
examined in every case of asthma, and any pathological condition there 
present should receive attention as the first step in the treatment. Spe- 
cial importance, in children, should be attached to the removal of adenoid 
growths o( the pharynx. 1 must admit, however, to have seen very few 
cases o( asthma (.aired or even greatly improved by these means. During 
attacks, the best means of relieving the symptoms is the inhalation of 
fumes of nitre paper or stramonium leaves. Most of the proprietary 
remedies (Papier de Fruneau, Himrod's cure, and Kidder's pastilles) 
contain these ingredients. The sleeping room may be rilled with the 
fumes of these substances, or the child may be placed in a tent into which 
the fumes are introduced. Emetics may be employed when the attack 
is brought on by indigestion. To prevent the recurrence of night attacks, 
nothing in my experience has been so valuable as a full dose of antipyrine 
at bedtime — four grains at five years and six grains at ten years. 
Between the attacks the main reliance should be upon the syrup of 
hydriodic acid (for a child of five years the dose is TTt v to TTt x, t.i.d.) 
and potassium iodide (gr. ii to gr. iv, t.i.d.), which are to be given 
for a long time. Tonics are to be used in nearly all cases. Those espe- 
cially valuable in asthmatic patients are cinchonidia (gr. ii, t.i.d.) and 
arsenic (gr. T -J-g-, t.i.d.). They may be advantageously combined. 

In the severe acute attacks nothing gives so much immediate relief as 
the use of adrenalin hypodermically — dose TTt v to a child of three years. 

In the cases of catarrhal asthma following bronchitis, expectorants 
and ordinary cough remedies are useless. Cod-liver oil and the iodide of 
potassium are valuable in some of the cases. Others are greatly relieved 
by the regular use of creosote inhalations several times a day, with a 
nightly dose of antipyrine. The fumes of nitre and stramonium often 
afford no relief, and sometimes the cases are made distinctly worse by 
them. The best of all measures is to send the child at once to a warm, 
dry climate. 

For all children who have had repeated attacks, whether in the form 
of hay fever or for those whose asthma is chiefly in the winter and spring 
and excited by attacks of bronchitis, the most important thing is re- 
moval to a place where they do not have the disease, and a residence 
there long enough to break up the tendency to recurrence. This will 
usually require several years. The region best suited to most asthmatics 
is one which is high, dry, and moderately warm. Some do exceedingly 
well at the seashore; others much better in the mountains. Patients 
often suffer less in cities than in the country. If taken early, asthma 
in children is frequently curable by these means; if neglected, the disease 
is almost sure to continue until adult life. 



PNEUMONIA. 489 

CHAPTEB IV. 

DISEASES OF THE LUNGS.— (Continued.) 
PNEUMONIA. 

In early life the lungs are more frequently the scat of organic di 
than any other organs in the body. Pneumonia is very common as a 
primary disease, and ranks first as a complication of the various forma 
of acute infectious disease of children. It is one of the large factors in 
the mortality of infancy and childhood. 

Cases of acute pneumonia are divided, from an anatomical point of 
view, into two principal groups: (1) Broncho-pneumonia, also known as 
catarrhal and as lobular pneumonia. (2) Lobar pneumonia, also known 







• sror 

* K\ 2 4 * 

Fig. 70. — Broncho-pneumonia. The picture shows at its centre one entire air vesicle, 
and at its margin parts of four or five other vesicles; they are filled with large epi- 
thelial cells having small nuclei. There are also seen leucocytes with intensely 
black nuclei and narrow protoplasm. Between the cells is a finely granular ma- 
terial, which is the exudation fluid coagulated during the hardening process. The 
alveolar septa are somewhat infiltrated. — From Karg and Schmorl. 

as croupous and as fibrinous pneumonia. These differ little from cadi 
other in etiology, but considerably in the products of inflammation, the 
distribution of the disease in the lung, and somewhat as to the parts 
involved and the nature of the changes in them. 

In broncho-pneumonia the large bronchi arc the Beat of a superficial 



401) 



DISEASES OF THE RESPIRATORY SYSTEM. 



inflammation, while in those of small size the entire bronchial wall is 
affected; the exudation into the air vesicles is mainly cellular, being 
made up of epithelial colls, leucocytes, and rod blood-cells (Fig. 70), 
fibrin being cither absent, or present only in small amount. In many 
cases there arc marked changes both in the alveolar septa and in the 
interstitial tissue of the lung; resolution is often imperfect, and there 
is a strong tendency for the inflammation to pass into a chronic form, 
involving the connective-tissue framework of the lung. The lesion is 
widely and often irregularly distributed, usually being most marked in 
the vicinity of the small bronchi from which the inflammation spreads, 
and in the most superficial lobules of the lung. 

In lobar pneumonia, bronchitis, when present, is usually superficial, 
the walls of the bronchi being very slightly or not at all affected; the 




Fig. 71. — Lobar Pneumonia. In the air vesicle shown in the picture there is a firm, 
close network of fibrin, in the meshes of which are leucocytes. At the lower part the 
exudation has contracted away from the wall in consequence of the process of hard- 
ening. — From Karg and Schmorl. 



same is true of the alveolar septa. The principal product of the inflam- 
mation is fibrin (Fig. 71), which fills the alveoli and the terminal bron- 
chi, the cells being relatively few and chiefly leucocytes. The process is 
usually sharply circumscribed, involving an entire lobe or a part of a 
lobe. In most cases it clears up rapidly and completely, there being but 
little tendency to involve the framework of the lung in a chronic process. 



PNEUMONIA. 491 

While in typical cases the two forms of inflammation are quite die 
tinct, there arc scon many intermediate forms which partake of the char- 
acters of both, and one may be in doubt, even after a microscopical ex- 
amination, in which group to place a case. II not infrequently happens 
that both varieties of pneumonia are present in different parts of the 
same lung or in both lungs at the same time. These mixed forms are 
especially frequent during the second and third years; hut during the 
first year, and after the third, the types are usually well marked. 

The following table shows the relative frequency of lobar and broncho- 
pneumonia in three hundred and seventy cases, 1 nearly all taken from 
one institution (New York Infant Asylum). There are included all 
the cases of acute primary pneumonia occurring during a period of 
seven years : 

Under six months, broncho-pneumonia, 73 cases; lobar pneumonia, 11 cases. 



Six to twelve 
Second year, 
Third " 
Fourth " 

Totals, 



96 " " " 29 

73 " " " 40 

19 " " " 23 

" " " 6 

261 " " " 109 



Thus it will be seen that, of the cases of acute pneumonia occurring 
during the first two years, twenty-five per cent were lobar and seventy- 
five per cent were broncho-pneumonia. 

When we come to a consideration of the micro-organisms with which 
the different forms of pneumonia are associated, we find that they do 
not correspond to the anatomical varieties. Lobar pneumonia is reg- 
ularly associated with the presence of the pneumococcus, but in a large 
number of cases other organisms are also found. In broncho-pneumonia 
there is almost always a mixed infection. In the primary cases the 
pneumococcus is usually the predominant organism, but it is commonly 
associated with the staphylococcus aureus. In the secondary cases, espe- 
cially when pneumonia follows measles or scarlet fever, the strepto- 
coccus is usually present, such cases being generally of a severe type. In 
the pneumonia of diphtheria, besides the streptococcus the diphtheria 
bacillus is frequently found. In winter the bacillus of influenza may he 
the only organism present, but it is usually associated with the pneu mo- 
coccus. The organisms mentioned are found in all possible combinations, 
sometimes one and sometimes another predominating. With any of them 
the bacillus of diphtheria or that of tuberculosis may be found. Some 
idea of the nature of the infection in broncho-pneumonia may be gained 
from the following table — the sputum cultures representing the pneu- 



1 The division was here made according to the predominant clinical or pathologi- 
cal features. Most of the doubtful cases were classed as broncho-pneumonia. 



492 DISEASES OF THE RESPIRATORY SYSTEM. 

monias o( one winter ami spring in the Babies' Hospital, and the post- 
mortem cultures from those o\' two seasons 1 in the same institution: 



Staphylococcus aureus 

Pneumoeoccus 

Streptococcus 

Bacillus influenzae 



Sputum cultures from 124 
casea of pneumonia. 



116 
94 
63 

47 



Post-mortem cultures from the 
lungs in 59 cases of pneumonia. 



36 
26 
17 
19 



Why the same exciting cause in one case produces broncho-pneumonia 
and in another lobar pneumonia may be in part owing to the difference 
in the structure of the lung at the different ages, especially the relatively 
large size of the bronchi in infancy. Again, in very young and in feeble 
children, the process tends to become diffuse and the products are chiefly 
cellular; in those who are older and more vigorous it is likely to be 
circumscribed, with fibrin as its chief product; in the intermediate ages 
and intermediate conditions the types are often mingled. 

The immediate source of infection of the lungs is the mouth or the 
rhino-pharynx. All the forms of bacteria found in pneumonia may be 
found in these cavities, some of them constantly, others only at certain 
times, especially during an attack of any of the acute infectious diseases. 
Provided the other conditions are favourable, pneumonia may be excited 
by direct contagion. This plays a small part in inducing primary pneu- 
monia ; there seems, however, to be little doubt that the secondary forms, 
especially the pneumonia complicating measles, diphtheria and influenza, 
are not infrequently communicated in this way. 

The different forms of pneumonia which will be considered are : ( 1 ) 
Acute broncho-pneumonia; (2) acute lobar pneumonia; (3) acute 
pleuro-pneumonia ; (4) hypostatic pneumonia; (5) chronic broncho- 
pneumonia. 

Tuberculous broncho-pneumonia will be discussed in the chapter 
devoted to Tuberculosis. 

ACUTE BRONCHO-PNEUMONIA. 

(Catarrhal Pneumonia; Lobular Pneumonia; Capillary Bronchitis.) 

This is essentially the pneumonia of infancy. Under two years, the 
great majority of the cases of primary pneumonia are of this variety, and 
throughout childhood nearly all the cases of secondary pneumonia. The 
term broncho-pneumonia describes a lesion rather than a disease, several 
quite distinct forms of infection being included under this head. Its 
mortality is high, because of the tender age of the patients in which the 

1 See Archives of Internal Medicine, v, 449; and Journal American Medical 
Association, lv, 1241. 



ACUTE BRONCHO-PNEUMONIA. 1!).', 

primary cases occur, and also because when secondary il complicates the 
most severe forms of the acute infectious diseases of children. 

Etiology. — The 426 cases of broncho-pneumonia of which I have 
notes occurred as follows: 

During the first year 224 cases, or 53 per cent. 

" " second year 142 " " 33 " 

" " third " 46 " " 11 " " 

" fourth " 10 " " 2 " " 

" fifth " 4 " " 1 " " 

426 100 

After four years broncho-pneumonia is infrequent as a primary dis- 
ease, although it is seen throughout childhood as a complication of the 
infectious diseases. 

Of the cases referred to, 38 per cent occurred during the winter 
months, 31 per cent during the spring, 13 per cent during the summer, 
and 18 per cent during the autumn. While, therefore, nearly 70 per cent 
of the cases occurred in the cold months, broncho-pneumonia is seen 
throughout the year. 

Broncho-pneumonia affects all classes, but is most frequent in chil^ 
dren having poor hygienic surroundings, especially in inmates of institu- 
tions, and in those previously debilitated by constitutional or local dis- 
ease. In 246 consecutive cases of primary pneumonia, 110 were in good 
condition prior to the attack, and 126 were delicate, rachitic, or syphilitic. 

The following table gives a good idea of the conditions with which 
acute broncho-pneumonia is most frequently seen; 443 cases were classed 
as follows: 

Primary * 164 

Secondary to bronchitis of the large tubes 41 

Complicating measles 89 

" pertussis 66 

" diphtheria 47 

" acute ileo-colitis 19 

" scarlet fever 7 

" influenza 6 

" varicella 2 

" erysipelas 2 

443 

A large number of the patients had previously suffered from one or 
more attacks of bronchitis, and fifteen previously had broncho-pneumonia. 

As an exciting cause, exposure to cold must still be classed among the 
potent factors of primary pneumonia. The organisms concerned in 
broncho-pneumonia have been discussed in the previous chapter. 

1 It is probable that a number of cases complicating influenza were included 
among these primary cases. 



494 



DISEASES OF THE RESPIRATORY SYSTEM. 



Lesions. — The term broncho-pneumonia is now generally adopted as 
a generic one, and it is to be preferred either to lobular or catarrhal 
pneumonia, as it gives prominence to the bronchial element in the inflam- 
mation. The process may begin in the larger tubes and gradually extend 




Fig. 72. — Broncho-pneumonia, with Thickening of a Bronchus. In the centre of 
the picture is seen a small bronchus, B, which is cut somewhat obliquely; the degree 
to which its wall, C, is thickened is well shown. It is partially filled with pus, its 
mucous membrane is nearly destroyed, and its walls greatly thickened from infiltra- 
tion with leucocytes. This infiltration extends to the lung tissue in the neighbour- 
hood; it forms a peri-bronchitic zone of pneumonia. Elsewhere in the picture the 
lung tissue, A, is practically normal. D is a small blood-vessel. E is another smaller 
bronchus. Throughout the lung everywhere accompanying the small bronchi similar 
changes were seen, in addition to which there were present some large areas of con- 
solidation. The disease was of four and a half weeks' duration ; the child, five months 
old. 

to those of smaller calibre, finally involving the pulmonary lobules in 
which these tubes terminate; or it may extend to the air vesicles which 
surround the tube in its course through the lung, so that in whatever 
direction the lung is cut, there are seen, surrounding the small bronchi, 
zones of pneumonia (Fig. 72). In other cases the process seems to begin 



PLATE XI. 




Acute Broncho-Pneumonia. 

Primary pneumonia in a child two years old, showing the irregular distribution of 
the consolidation and its incomplete character. A is the pleura somewhal thickened : 
B, lung tissue which is practically normal; C C are consolidated areas, scattered through 

which are groups of air vesicles still containing air. (Slightly magnified.) 



ACUTE BRONCHO PNEUMONIA. 495 

almost at the same time in the small bronchi and the air vesicles, as both 
are found involved, even when death occurs within a Few hours of the 

first symptoms. 

There are, however, cases in which the parts of the Lung affected 
bear no relation to the bronchi — where there are found simply smaller 
or larger areas of pneumonia irregularly Scattered through the lung, 

usually near the surface (Plate XT). From the distribution of the 
lesions such cases might better be termed lobular than broncho-pneu- 
monia. 

Much has been said in the past about pulmonary collapse from ob- 
struction of the small bronchi, as a condition antecedent to this form of 
pulmonary inflammation. So far as my own observations go, there has 
been adduced but little evidence that this is the rule, or, indeed, that it 
often occurs. Even in autopsies made very early in the disease, but little 
collapse is found, most of the cases supporting the view of Delafield, that 
when the disease extends from the bronchi to the air cells it involves 
those surrounding the tube quite as regularly as those to which the tube 
leads. 

The following observations are made from a study of 170 autopsies 
of which I have records, microscopical examinations having been made in 
about one-third of the number. 

Seat of the Disease. — In eighty-two per cent of the autopsies extensive 
disease was found in both lungs. The parts most affected were the lower 
lobes posteriorly; next to this the posterior part of both the upper and 
lower lobes. The left lower lobe was more extensively diseased than the 
right in over two-thirds of the cases. If the pneumonia is in front onl} r , 
the right apex is the most frequent seat. 

There are a certain number of cases which appear to follow tolerably 
well-defined stages of congestion, consolidation, and resolution; but the 
disease may be arrested at any of the stages and the case recover, or 
death may occur at any stage and there may -be found at autopsy differ- 
ent portions of the lung representing all the stages mentioned. In con- 
sidering, therefore, the lesions of broncho-pneumonia, it seems best to 
describe the condition in which the lungs are found at the various periods 
when death is likely to occur, rather than to attempt to describe the 
different stages of the disease, as in lobar pneumonia. 

1. The Acute Congestive Form (Acute Bed Pneumonia). — This is 
the condition in which the lung is usually found if death occurs during 
the first two or three days of the disease. In the cases severe enough to 
cause death in the first twenty-four hours, very little can be seen by the 
naked eye except acute congestion. The vessels of the pleura are dis- 
tended, and there may be small superficial haemorrhages. Both lower 
lobes are usually heavy and dark coloured. There is to the naked eye 
no consolidation. All, or nearly all, the lung can he inflated. On 



400 DISEASES OF THE RESPIRATORY SYSTEM. 

t ion. there is found intense congestion with some oedema. When the 
process has lasted a little longer the affected areas are more sharply 
defined. These, usually the posterior portions of both lungs, are of a 
brownish-red colour, and appear partially consolidated, although with 
a little force they may in most eases be inflated. After section, pus and 
mucus flow from the divided bronchi, and the whole lung may be more 
or less congested or cedematous. 

The microscope alone reveals the fact that these are not cases of sim- 
ple pulmonary congestion or bronchitis of the finer tubes. In one case 
in which death occurred twelve hours from the first symptoms, I found 
well-marked evidences of inflammation of the air vesicles. In these 
hyper-acute eases, the microscope shows great distention of all the small 
blood-vessels of the affected area, and small or large extravasations of 
blood just beneath the pleura, into the alveoli and interstitial tissue of the 
lung. In some cases these haemorrhages form the most striking feature 
of the lesion. The air vesicles are partially, some almost completely, 
filled with red blood-cells, swollen and desquamated epithelial cells, and 
a few leucocytes (Fig. 70). The red blood-cells predominate. The in- 
flammation may be diffuse, involving nearly a whole lobe, or in small 
areas in the neighbourhood of the small bronchi. The mucous mem- 
brane of the large and small bronchi is the seat of catarrhal inflammation, 
and the walls of the latter are infiltrated with round cells. 

When the process has lasted from twenty-four to forty-eight hours 
all the changes described are more marked, but the red colour of the 
inflammatory products still persists. Such cases give during life only 
the signs of congestion and bronchitis. 

2. The Mottled, Red and Gray Pneumonia. — This is the usual ap- 
pearance when the disease has lasted somewhat longer, and is found in 
most of the cases dying between the fourth and fourteenth days. There 
are usually at this time quite large areas of consolidation, sometimes 
affecting nearly an entire lobe, so that at first sight the case may resemble 
lobar pneumonia. This is sometimes described as the " pseudo-lobar " 
form. The extent of these areas depends largely upon the duration of 
the disease. In most cases there is pleurisy over the consolidated por- 
tions. This may cause the lung to adhere to the chest wall, the firmness 
of the adhesions depending upon the duration of the process. The sur- 
face of the lung is usually of a mottled red and gray colour ; it often has 
a coarsely granular feel, due to the consolidation of some of the super- 
ficial lobules of the lung. On section, it is rarely found that an entire 
lobe is consolidated, the superficial portion being most affected, while 
the central part is normal or only congested. The colour is mottled, like 
that of the surface. In some places the consolidation appears complete ; 
in others the consolidated areas are separated by healthy, congested, or 
emphysematous lung tissue (Fig. 73). The gray areas surround the 



ACUTE BRONCHO-PNEUM( )M A 



497 



small bronchi and vary in size. The smallest ones look very much like 
miliary tubercles. The larger ones are seen where the process has existed 
for a longer time and has gradually invaded the contiguous air cells. If 
the lung is cut parallel with the bronchi, there may be Been small gray 
striae of pneumonia along their course (Fig. 72, ('). From the cul 
bronchi, pus flows quite freely on pressure. The bronchial walls are 




Fig. 73. — Acute Broncho-pneumonia. In the centre is shown a small bronchus, B, 
with a zone of pneumonia about it. The greater part of the section is made up of 
emphysematous lung tissue, E E, showing dilatation of the alveolar spaces and rup- 
ture of some of the alveolar septa. At the border, AAA, are seen the margins of 
consolidated areas of lung. 

often seen to be thickened even by the naked eye. The parts affected 
are usually the posterior portions of the lower lobe of one or both sides, 
the remainder of the lobes being congested or oedematous, while in front 
the lung is emphysematous. 

Under the microscope the smaller bronchi (Fig. 72) are seen to be 
much thickened and infiltrated with leucocytes. The gray areas sur- 
rounding the bronchi are made up of groups of air vesicles, which are 
packed with leucocytes (Fig. 74). Fibrin is sometimes seen in small 
amount, also red blood-cells and desquamated epithelial cells, but the 
leucocytes predominate. Surrounding the areas densely infiltrated are 
groups of air vesicles which are normal or congested, or which show- 
only the earlier stages of the inflammatory process. 
33 



498 



DISEASES OV THE RESPIRATORY SYSTEM. 



Gray Pneumonia (Persistent Broncho-pneumonia). — Tins form 
i- seen in protracted cases whore there have been continuous symptoms 
usually for from three to six weeks. The pleuritic adhesions are more 
genera] ami firmer. The amount of lung - involved may be very great, 
often nearly the whole of both lungs posteriorly. The affected lung ap- 
pears completely consolidated and slightly enlarged. On section, it is 
of a nearly uniform gray colour, sometimes of a yellowish-gra} r . On 




Fig. 74. — Broncho-pneumonia. Dense infiltration of pus cells in and about a small 
bronchus; under a low power. The cavity shown in the specimen is a cross-section 
of one of the small bronchi, which is partially filled with pus cells; the epithelium is 
destroyed. The bronchial wall and the pulmonary tissue in the neighbourhood are so 
densely infiltrated with leucocytes that almost every trace of normal structure is 
effaced. Child fifteen months old, disease of four weeks' duration. Extensive areas 
like this were found in both lungs. 



pressure, pus exudes from the smaller and larger bronchi. The bronchial 
walls are markedly thickened, and in some places there may be a slight 
dilatation of the smaller bronchi. The part of the lung not consolidated 
may he almost white, owing to vesicular emphysema. In some cases 
there is also interstitial emphysema. Small cavities containing pus may 



ACUTE BRONCHO-PNEUMONIA. 



499 



be found in the lung-. The bronchial -lands are frequently swollen to 
the size of a large bean, and are of a reddish-gray colour. 

The microscope shows that the an- vesicles of the consolidated por- 
tions are distended chiefly with leucocytes, hut then- are also epithelial 



'/m 



I m ■»■• 



ft 



Fig. 75. — Persistent Broncho-pneumonia; Highly Magnified. There is shown at 
A A marked thickening of the alveolar septa, encroaching upon the alveolar spaces. 
All the alveoli, B B, are densely packed with leucocytes. A similar condition also 
through nearly the whole of the affected lung. (For history and temperature, see 
Fig. 84.) 

and connective-tissue cells. The alveolar septa may be so much thick- 
ened as to encroach upon the alveolar spaces (Fig. 75). Complete i< 
lution is then impossible. 

Terminations. — Death may occur at any stage, or the pathological 
process may be arrested at any stage and the case go en to recovery. 
Resolution may take place before any consolidation recognisable by phys- 
ical signs has occurred; in such cases it is usually rapid and complete. 
If there has been consolidation, resolution may take place after two or 
three weeks and be complete, or it may be delayed for five or six weeks 



500 DISEASES OF THE RESPIRATORY SYSTEM. 

and still be complete. In many cm eially those in which it is 

delayed, resolution is only partial, and there are relapses or recurring 
attacks r the first, or after several attacks, there may develop a 

chronic- interstitial pneumonia; or simple pneumonia may be followed 
by tuberculosis. Such cases as these are to be carefully distinguished 
from the much more frequent ones in which the broncho-pneumonia is 
tuberculous from the outset. 

Associated Lesions of the Lungs. — Pleurisy is almost invariably found 
over every large area of consolidation, and in cases of more than three or 
four days' duration: while in most of those fatal within the first two 
or three days the pleura is normal or only congested. It is seen in all 
grades of severity, from a slight gray film of fibrin that can hardly be 
stripped off. to a yellowish-green exudation one-fourth of an inch thick. 
A small amount of serum — one or two ounces — in the pleural sac is not 
uncommon, but a large serous effusion is very rare. Cases in which there 
is an excessive inflammation of the pleura are considered elsewhere under 
the head of Pleuro-pneumonia. Empyema occurs both during the stage 
of acute inflammation of the lung and while this is subsiding, but it is 
less frequent than in lobar pneumonia. 

Bronchial Glands. — In all the recent acute cases these are swollen 
and red ; the usual size is that of a pea or a bean. They show microscopic- 
ally the usual changes of acute hyperplasia. In protracted cases, and 
after repeated attacks, they may be two or three times the size mentioned, 
and of a gray colour. It is rare that they are large enough to give rise 
to symptoms nnless they become the seat of tuberculous deposits. 

Emphysema. — This is one of the regular and striking features of 
acute broncho-pneumonia in infancy, it being especially marked in the 
protracted cases. It is usually vesicular, involving the greater part of 
the upper lobes in front and the anterior margin of the lower lobes. Oc- 
casionally interstitial emphysema is seen, forming either large stria? upon 
the surface of the lung, or blebs of considerable size along the anterior 
margin. This may occur even in cases uncomplicated by pertussis or 
laryngeal stenosis. 

Gangrene. — Gangrenous areas were found in six cases of the series 
mentioned. In four of these the pneumonia was primary, in one it 
followed diphtheria, and in one ileo-colitis. It occurred in scattered areas 
of a grayish-green colour, varying from one-fourth of an inch to two 
inches in diameter. 

Abscesses of the lung are by no means uncommon. They were noted 
in seven per cent of the autopsies. They are usually minute and mul- 
tiple, varying in size from one-sixth to one-half inch in diameter. Some- 
times a portion of a lobe is fairly honeycombed with minute abscesses. 
In one case a large abscess was found occupying the greater part of a 
lobe, the symptoms resembling those of empyema. Abscesses are usually 



ACUTE BRONCHO-PNEUMONIA. 501 

found in regions where the inflammatory process has been especially 
intense. They may be found in prolonged cases, in those of unusual se- 
verity, as shown by excessively high temperature and rapid extension of 

the disease, and in very delicate subjects. The microscope showa that 
these abscesses usually begin as an accumulation of pus in the small 
bronchi, whose walls become softened and break down on account of the 
intensity of the inflammation. They may be superficial, but are more 
commonly in the interior of the lung; they contain yellow pus and 
sometimes broken-down lung tissue. Small abscesses can not be recog- 
nised clinically ; the large ones give the symptoms and signs of empyema. 
They are discussed more fully elsewhere. In several instances they have 
been successfully operated on, though wrongly diagnosticated. 

The lesions in other organs will be considered under Complications. 

Symptoms. — Broncho-pneumonia has no typical course. The cases 
differ from each other very markedly, but they may be divided into a 
few quite distinct groups. 

1. The Acute Congestive Type. — This may be seen at any age, but 
is more frequent in young infants. It may be either primary or secondary, 
being not uncommon in either form. Its symptoms are few and irreg- 
ular, and the disease is often unrecognised. The entire duration may 
be only twenty-four hours. High temperature, extreme prostration, 
cyanosis, and rapid respiration may be the only symptoms. The tem- 
perature varies between 104° and 107° F., usually rising steadily until 
death occurs. The prostration is extreme from the outset, the patient 
being overwhelmed by the suddenness and severity of the attack. Cya- 
nosis is frequently present, and is almost always seen shortly before death. 
The respirations are from 60 to 80 a minute, but in most cases not strik- 
ingly laboured. Cough is frequently absent. Cerebral symptoms are 
often marked. There are dulness and apathy, sometimes quite profound 
stupor, and not infrequently convulsions just before death. The physical 
signs are few and inconclusive. There is often nothing abnormal except 
very rude breathing over both lungs behind; sometimes the breathing 
on one side is feeble, and on the other much exaggerated. There may 
be no rales whatever, and no change in the percussion note. 

The suddenness and severity of these symptoms are something which 
it is hard for one who has not observed them to appreciate. I have 
known an infant to die in twelve hours from the time in which he was 
apparently in perfect health, and had an opportunity to confirm the 
diagnosis of pneumonia by a microscopical examination of the lung. The 
diagnosis can not be positively made during life, and in most of the cases 
the disease passes under some other name. It is often regarded as malig- 
nant scarlet fever or measles with suppressed eruption, or cerebro-spinal 
meningitis. 

If the children are sufficiently strong to withstand the onset of vio- 



502 DISEASES OF THE RESPIRATORY SYSTEM. 

lent symptoms, they may recover completely in four or rive days, the 
lung clearing up very rapidly. In other cases these grave symptoms may 
abate in a day or two, to be followed by those of ordinary broncho- 
pneumonia, which runs its usual course. 

The symptoms Of some of these cases may be explained by the sudden 
intense engorgement of the lung, which, owing to the small size of the 
air vesicles, interferes with its function almost as much as does consoli- 
dation. In other cases the symptoms are due not so much to the pulmo- 
nary condition as to a general pneumococcus infection. A case lately 
came under my notice in which death occurred after a thirty hours' ill- 
ness, where the pneumococcus was found by culture in both kidneys, the 
spleen, heart's blood, and both lungs. 

'2. Acute Disseminated Broxcho-pxeumoxia (Capillary Bron- 
chitis). — Although the symptoms in this class of cases are chiefly due to 
the bronchitis, I have never failed to find at autopsy evidences of pneu- 
monia also. These are not very common cases. The process begins as an 
inflammation of the medium-sized and small bronchi, but not of the 
finest bronchi. The onset is acute, with fever, very rapid and laboured 
breathing, severe cough, moderate prostration, and in most cases 
cyanosis. 

The temperature is not high, usually only from 100° to 102° F., and 
it often continues so for three or four days. The pulse is rapid, and at 
first is full and strong. The respirations are exceedingly rapid, often 
from 80 to 100 a minute. There is dyspnoea with marked recession of 
all the soft parts of the chest during inspiration. Cough is alwa) r s pres- 
ent, usually severe, and sometimes almost incessant. The prostration is 
not so great as in the cases previously described, and the development of 
the symptoms is much less rapid. 

There are at first sibilant and afterward subcrepitant rales over the 
entire chest, with which are usually mingled coarser moist rales. There 
are no evidences of consolidation. The respiratory murmur is every- 
where feeble, but not otherwise altered. Percussion generally gives ex- 
aggerated resonance, owing to the emphysema which is present, the note 
being sometimes almost tympanitic. 

The symptoms may gradually increase in severity until death takes 
place by the third or fourth day, from respiratory or cardiac failure. 
There is usually marked cyanosis, and toward the end rapidly increasing 
prostration. Just before death the temperature often rises rapidly to 
106° or 107° F. At the autopsy there are found evidences of bronchitis 
of the tubes of all sizes, and minute zones of pneumonia about the smaller 
bronchi. The lungs are generally in a state of hyper-inflation, on account 
of which they do not collapse on opening the chest. There may be in 
addition extensive congestion or oedema, the development of which has 
been the immediate cause of death. 



ACUTE BRONCHO-PNEUMONIA. 503 

In cases which do not prove fatal there is usually by the third or 
fourth day great improvement in the general symptoms; the liner rales 
may disappear, and the coarse ones become more and more prominent. 
By the end of a week there may he complete recovery, Instead of this, 
there may be a continuance of the constitutional symptoms, and disap- 
pearance of the fine rales in front only, while behind there are gradually 
added to them the signs of consolidation in one of the lower lobes mar 
the spine. From this time the case may progress as one of ordinary 
broncho-pneumonia. 

The prognosis in this class of cases is very much better than in the 
congestive variety, recovery being probable unless the patients are very 
young or very delicate infants. 

3. Bboncho-pneumonia of the Common Type. — When primary, 
this usually begins suddenly with symptoms not unlike those of lobar 
pneumonia. This was the mode of onset in two-thirds of my cases. 
In only ten per cent was the pneumonia preceded by bronchitis of the 
large tubes. In these the symptoms of bronchitis may slowly or rapidly 
(Fig. 76) merge into those of pneumonia. When the onset is sudden 
it is marked by high fever, frequently by vomiting, rarely by convul- 
sions. In addition there are rapid respiration, cough, prostration, and 
sometimes cyanosis. The symptoms are more distinctly pulmonary than 
is generally the case in lobar pneumonia. 

The temperature, as a rule, is high ; rarely is it continuously so, but 
it is of a remittent type. The daily fluctuations often amount to four or 
five degrees. The fever usually continues from one to three weeks, and 
gradually subsides. It is rare for it to terminate by crisis. Although, 
as a rule, we expect a high temperature with acute pneumonia, this is 
not invariable. Primary cases may run their course, and even terminate 
fatally, although the temperature has not been above 101° F. I have 
records of several such cases. A low temperature is more often seen 
in young and delicate infants than in those who are older and more 
robust. 

The respirations are frequent and laboured; there is real dyspnoea. 
On inspiration, there are marked recessions of all the soft parts of the 
chest, and the ala? nasi dilate actively. The usual rapidity of the respira- 
tions is from 60 to 80 per minute; very often, however, it rises to 100, 
and on several occasions I have seen it even 120. Respiration generally 
seems more embarrassed than does the action of the heart, and respiratory 
failure is a more frequent cause of death than cardiac failure. The 
pulse is always rapid — from 150 to 200 a minute — and when so it is often 
irregular. The pulse rate is of much less importance than its character. 
Early it is full and strong, but soon it becomes soft, compressible, and 
weak. 

The prostration is usually moderate for the first day or two, but 



504 DISEASES OF THE RESPIRATORY SYSTEM. 

steadily increases as the lung becomes more and more involved, and 
toward the close of the disease may be extreme. 

Cough is much more constant than in lobar pneumonia, and more 
distressing: sometimes it is almost incessant. It disturbs rest and sleep, 
and may cause vomiting if the paroxysm occurs soon after eating. There 
is no expectoration. Mucus is sometimes coughed up into the trachea, or 
even the pharynx, to be swallowed again, or more frequently aspirated 
into the lung. If during a severe paroxysm the patient is turned upon 
his face or inverted, much of this mucus may be dislodged. A strong 
cough is a good symptom ; suppression of the cough is a bad symptom, 
indicating a loss of the reflex sensibility of the bronchial mucous mem- 
brane and of the respiratory centre. 

Pain in the chest is not common, and is rarely an annoying 
symptom. 

Cyanosis is present at some time in most of the severe cases. It may 
occur at the onset, or at any time during the course of the disease. It 
is usually due to sudden congestion of a portion of the lung not previ- 
ously involved. Even when slight, it is always a danger-signal of re- 
spiratory failure, and when present only in the finger tips or lips indi- 
cates that the patient must be carefully watched and energetically treated. 
In the severe cases the whole body may be of a dull leaden hue. 

Xervous symptoms at the onset are not so frequent as in lobar pneu- 
monia, convulsions being rare; but late convulsions, particularly in the 
pneumonia which complicates pertussis, are frequent, and when present 
the disease is usually fatal. Delirium may occur at any time during the 
attack. In infants this shows itself by excitement and inability to recog- 
nise the nurse or mother. Occasionally patients present marked cerebral 
symptoms throughout the disease closely simulating meningitis. As 
elsewhere stated, the nervous symptoms depend not upon the location of 
the disease, but upon its extent, the intensity of the infection, and upon 
the susceptibility of the patient, such symptoms being especially common 
in rachitic children and in those suffering from pertussis. 

Gastro-enteric symptoms are frequent in infancy, and are of much 
importance. Often there are from four to six stools a day, of a green 
colour, containing mucus and undigested food. These symptoms depend 
upon the feeble digestion which is associated with the febrile process, 
and are often aggravated by improper feeding and overmedication. Vom- 
iting and diarrhoea add much to the danger of the attack. In summer 
this complication is more frequent and is likely to be more severe. Dis- 
tention of the stomach or intestines from gas may be the cause of dis- 
tressing symptoms, owing to the added embarrassment of respiration 
produced by this upward pressure. In infants it may lead to attacks of 
cyanosis, and even to convulsions. 

The blood in acute broncho-pneumonia shows regularly the changes 



ACUTE BRONCHO-PNEUMONIA. 



505 



of a moderate secondary anaemia, which in protracted cases becom« 
marked. A leucocytosis is almost invariably present. In an average 
case this ranges from 20,000 to 40,000. It sometimes is excessively high 
without any apparent reason. I have several times seen it over 100,000. 
The increase is chiefly in the polymorphonuclear cells which usually 
form from sixty to eighty per cent of the total leucocytes. With the fall 
in temperature the leucocytosis in most cases rapidly disappears. A 
rapid diminution in the leucocytosis may indicate a marked lose of re- 
sistance in the patient; and may be seen with either a high or a low- 
temperature. In the pneumonia which complicates pertussis, the in- 
crease in the white cells is chiefly 
of the lymphocytes. 

The urine in most cases is 
scanty, high-coloured, and loaded 
with urates. A trace of al- 
bumin is often present when 
the temperature is very high ; 
but casts, renal epithelium, and 
a large amount of albumin are 
rare. 

The accompanying tempera- 
ture chart (Fig. 76) is a good 
example of a very frequent course of primary pneumonia of moderate 
severity terminating in recovery. In cases of this type the constitu- 
tional symptoms are not grave, and follow very closely the temperature 
curve. 

The next chart (Fig. 77) illustrates a more severe but not uncom- 
mon course of the disease in which the fever is prolonged. The usual 



105° 
101° 
103° 
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101° 
100° 
99° 


ill 


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Fig. 76. — Temperature Curve in Typical 
Broncho-pneumonia of the Milder Form. 
History. — Male, sixteen months old ; delicate 
child; previous bronchitis; onset gradual; 
signs of consolidation at left base on fifth 
day, but fine rales over both lower lobes 
behind; resolution slow, rales persisting for 
a long time in both lungs. 



107° 
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Fig. 77. — Temperature Curve of Broncho-pneumonia with a Prolonged Course; 
Recovery. History. — Female, eighteen months old; in fair condition; sudden onset. 
Early signs were localised, fine rales over left base; on fifth day signs of consolidation 
at left base, with rales on both sides behind. General symptoms of moderate severity. 
Signs of consolidation disappeared about a week after cessation of fever: rales per- 
sisted nearly two weeks longer. 



duration of cases of this type is between three and four weeks. The 
irregular fluctuations of the temperature, rarely touching the normal line, 
are exceedingly characteristic of broncho-pneumonia. 



506 



DISEASES OV THE RESPIRATORY SYSTEM. 



The chart shown in Fig, 78 is that of relapsing pneumonia. The 

first attack was fairly typical, with about the usual duration. Resohi- 



107= 12 3 4 S 8 7 8 '.' 10 11 


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Fig. 78. — Temperature Curve of Relapsing Broncho-pneumonia; Recovery. 

History. — Male, nineteen months old ; delicate. Consolidation on sixth day in left lower 
lobe behind; two days later small area of consolidation in right lower lobe behind; 
many rales both sides; eighteenth day, signs of consolidation had disappeared, but 
many rales persisted. Accession of fever on nineteenth and twentieth days, accom- 
panied by extension of disease as shown by new rales, but no evidences of consolida- 
tion during second attack. Slow resolution and convalescence. 

tion had begun, and was apparently progressing favourably, when there 
was a return of the fever, accompanied by new signs in the chest, the 

second attack being shorter and milder than 
the first. Very often the temperature falls 
to normal without any signs of resolution, 
and after an interval varying from two or 
three days to a week there is a recurrence of 
the fever and other constitutional symp- 
toms, the second attack frequently proving 
fatal. 

A frequent course in fatal cases is shown 

in Fig: 79. The duration of the disease, 

chitic; sudden onset. Signs instead of being five days as in this case, is 

first day were fine moist rales £i _ -, ■ -, » mi 

throughout the chest, marked often onl y three or four - The temperature 
prostration, and cyanosis; on at first fluctuates widely, then rises grad- 

third day, a small area of con- uaUy ^ deatk 

Duration of the Fever. — The following 
figures give the duration of the fever in 
231 cases. The majority were primary; 





l\ 2 | H | 4 


6 1 6 7 


107° 
106° 
105° 
101° 
103° 
102° 
101° 
100° 
99° 






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Fig. 79. — Temperature Curve 
of Broncho - pneumonia; 
Fatal. History. — Male, six 
months old; markedly ra- 



solidation in upper lobe of left 
lung behind; increasing pros- 
tration, cyanosis, and death. 
Autopsy. — No pleurisy; con- 
solidation at left apex behind, 



and posterior two-thirds of left none were secondary to diphtheria, and 



lower lobe; consolidation of 
right apex posteriorly, lower 
lobe intensely congested. 



only a few complicated measles. 
169 cases that were fatal — 



Of the 



There died during the first six days 25 . per cent. 

" " between the seventh and twenty-first days. 55.5 " " 
" twenty-first and sixtieth days. 19.5 " " 



100.0 



Of 78 cases which recovered, the duration of the fever was — 



ACUTE BRONCHO-PNEUMONIA. .",07 

Less than seven days 11 o p<*r cent . 

From seven to twenty-one days 66.6 " " 

" twenty-one to ninety days 21.9 " " 

100.0 " 

Physical Signs. — Tn considering the Bigns of broncho-pneumonia, ii ifl 

better to connect them with the different conditions in the lung than to 
group them in stages, as in lobar pneumonia. 

( i) Without Consolidation. — It can not too often be repeated that 
broncho-pneumonia may exist without Bigns of consolidation at any 
period during the course of the disease. When the attack is primary, the 
earliest signs are due to congestion of the lung, associated with bronchitis 
of the fine tubes, which is usually localised, but which may be general. 
If the disease has followed bronchitis of the large tubes, its signs are 
added. Congestion of the lung gives feeble breathing over the affected 
area, and occasionally slight dulness or diminished resonance. With this 
are found coarse sonorous, and finer sibilant rales, due to congestion and 
swelling of the mucous membrane of the larger and smaller bronchi 
respectively. These signs are soon replaced by very fine moist rales, 
which are usually localised in one of the lower lobes behind (Fig. 80). 
These localised fine rales are the first distinctive sign of broncho-pneu- 
monia. Soon a change in the respiratory murmur is heard in the affected 
area, which becomes feebler in intensity and higher in pitch. Elsewhere 
in the chest there may be coarse rales, due to bronchitis of the large tubes. 
In such cases the areas of pneumonia are so small and so scattered as to 
give in themselves no additional signs, and the case may go on to recovery 
without presenting anything more distinctive than the signs mentioned. 

(b) With Areas of Partial Consolidation. — In the lung at this 
time there are small areas of consolidation, generally superficial and 
separated by healthy or congested lobules. Percussion in these cases 
usually gives negative results, but sometimes there is very slight dulness. 
The vocal fremitus is not usually altered. The fine moist rales may be 
heard over quite a large area, but at some point, usually near the spine, 
over one of the lower lobes, they are sharper, louder, higher pitched, and 
more metallic, and seem close under the ear (Fig. 81). Respiration is 
feebler here than elsewhere, and broncho-vesicular in quality, approach- 
ing bronchial breathing more and more as the consolidation increases. 
The resonance of the voice and cry is exaggerated. 

(c) WitJi Areas of Consolidation More or Less Complete. — On 
percussion there is dulness, but surprisingly little in comparison with 
the other signs of consolidation present. It is due to the fact that 
the consolidated portion, though extensive, does not involve the Lung 
to any great depth, and also that there are in the consolidated area 
many alveoli which still contain air (Plate XI). On palpation there 
is usually a slight increase in the vocal fremitus. On auscultation, there 




Fig. 80. — First Stage. Coarse rales over both 
lungs; localised fine (subcrepitant) rales at the 
left base. No change in breath sounds. 



Fig. 81. — Second Stage. Coarse and fine rales 
over both lungs behind; at left base an area 
of partial consolidation, with broncho-vesic- 
ular breathing, exaggerated voice, and very 
sharp rales. 




Fig. 82. — Third Stage. A larger area of partial Fig. 83. — Fourth Stage. Extensive disease of 



consolidation, and in the centre a small area of 
complete consolidation, with bronchial breath- 
ing and voice and slight dulness. Signs over 
the right lung similar to what were previously 
present over the left. 



both sides; large area of complete consoli- 
dation on the left, with dulness, bronchial 
breathing and voice, and no rales; surround- 
ing this, broncho-vesicular breathing, with 
many rales. Signs in the right lung similar 
to those previously present over the left. 



Note. — The large circles indicate coarse rales; the small ones finer rales; the red areas 
indicate consolidation partial or complete. The disease may stop at any one of these stages 
and resolution take place. 
508 



ACUTE BRONCHO-PNEUMONIA. 509 

are still present the evidences of bronchitis, usually only behind, bu1 

sometimes over the entire chest. Coarse and fine pales are inter- 
mingled. Over the consolidated parts arc beard bronchia] breath- 
ing and bronchial voice. At the centre of these areas the bronchial 

breathing is pure and rales are usually absent, but at the margin 
rales are present and the breathing approaches the broncho-vesicular 
type (Fig. 82). The signs of consolidation are rarely sharply circum- 
scribed as they are in lobar pneumonia, but shade off gradually. The 
consolidated area is at first small, usually in one of the lower lobes near 
the spine, but may gradually extend until nearly the whole of one or 
even both lungs behind are more or less completely solidified (Fig. S3). 
The signs are found as far forward as the axillary line, but usually stop 
there. Friction sounds may be heard over the consolidated areas, but 
very rarely except where signs of complete consolidation are present. It 
is often impossible to obtain any idea of the condition of an infant's lung 
during quiet, superficial respiration. Sometimes over a part which is 
completely consolidated there is heard only very feeble breathing, or 
the lung may be almost silent. If, however, the child is made to cry 
or to take a deep inspiration, both the bronchial breathing and rales are 
distinctly brought out. The intensity of the consolidation increases as 
the case advances, and the signs become more and more like those of lobar 
pneumonia. During resolution there is first a disappearance of the 
signs of consolidation, which may be quite rapid, but friction sounds 
and rales of all kinds often persist for three or four weeks longer. 

The following statistics are of some interest, as showing the frequency 
with which signs of consolidation were found, and the day when they 
were discovered. Their value is increased by the fact that the children 
were under observation in an institution at the time they were taken 
sick, and that in all the fatal cases — thirty-six in number — in which signs 
of consolidation were absent, the diagnosis of pneumonia was confirmed 
by autopsy: 

Consolidation noted on or before the fourth day 47 cases. 

" from the fifth to the seventh day 36 " 

" " "the eighth to the twelfth day. . . . 12 " 

." after the twelfth day 9 " 

No signs of consolidation 62 

106 

In general, it must be borne in mind that in many cases signs of 
consolidation are never present, as the areas of pneumonia are small and 
widely scattered; that where there is consolidation it is usually incom- 
plete, because there are small areas of healthy lung tissue between the 
hepatised portions; that the signs of consolidation usually shade oil' 
gradually; and that both sides are almost invariably involved, although 
one side usually to a greater degree than the other. 



510 



DISEASES OF THE RESPIRATORY SYSTEM. 



i. The Protracted Form — Persistent Broncho-pneumonia. — 

This is seen in primary cases, especially among delicate children, and 
m the pneumonia complicating pertussis, influenza and measles, and is 
the form which often follows diphtheria. The onset and course of the 
disease for the first two or three weeks do not differ from an ordinary 
attack of moderate severity, but at the end of this period there is seen 
no tendency in the process to subside. The fever continues, although it 
may not be high, but by physical examination it is found that the areas of 
consolidation are gradually increasing day by day, until sometimes the 
greater part of both lungs behind are involved. The air vesicles become 
so distended with cells that the signs of consolidation are more complete 
than in ordinary broncho-pneumonia. There is marked dulness, some- 
times almost flatness; bronchial breathing is exaggerated in intensity, 
until it resembles cavernous breathing, and it may be impossible to dis- 
tinguish between them. However, the fact that it is heard over so large 
an area, that it shades off gradually, and that it is accompanied by fric- 
tion sounds, usually make a distinction possible. 

The temperature in these protracted cases for the first two or three 
weeks is from 100° to 105° F. ; but after this time it is generally lower 
—from 100° to 102° or 103° F. The course is not at all regular, but 



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W°kl 1 1 i 1 1 ! 1 I 1 1 1 1 1 1 1 1 i I 1 1 i "1 1 1 1 1 1 1 i 1 1 M 1 1 1 1 1 1 1 1 1 1 I 1 1 1 ! I 



Fig 



84. — Temperature Curve of Persistent Broncho-pneumonia, Terminating 
Fatally. History. — Male, two and a half years old; healthy; sudden onset; for two 
weeks the only signs were very fine moist rales throughout both lungs, front and back. 
The rales in front in great part gradually cleared up; those behind persisted, but it was 
not until the thirty-fourth day that positive signs of consolidation were discovered in 
the left lower lobe behind; these signs gradually extended, and, before death, were 
present over nearly the whole left lung behind and over the right lower lobe. There 
were also friction sounds over both lungs. Autopsy. — Old and recent pleurisy with 
general adhesions; left lower lobe completely solid, patches of consolidation in left 
upper lobe. Right lower lobe about one-half consolidated, with patches elsewhere. 
Bronchial glands large, but not cheesy. No evidence of tuberculosis upon either 
gross or microscopical examination (see Fig. 75). 



marked by frequent exacerbations and remissions. The general symptoms 
are those of progressive asthenia. There is continued wasting, anaemia, 
and steadily increasing prostration. The appetite is lost, often there is 
an aversion to food, and vomiting is easily excited if food or stimulants 
are forced. The stools show that even what food is taken is very im- 
perfectly digested and assimilated. The skin becomes dry and loses its 
elasticity ; bed-sores may form ; fine punctate haemorrhages are seen over 
the abdomen, sometimes over the chest and extremities. The latter is 



ACUTE BRONCHO PNEUMONIA. 



511 



always a very bad symptom, and I have never seen recovery from pneu- 
monia when it was present. 

Death takes place from slow asthenia, usually after five or six v. 
but the attack may be prolonged for eight or ten weeks. The general 
symptoms, the temperature, and the wasting strikingly resemble cases of 
tuberculosis, and such is the diagnosis often made. 

Although the majority of the cases in which the fever lasts over four 
weeks run the fatal course just described, such apparently hopeless cases 
occasionally recover. The temperature gradually falls lower and lower, 
until it remains at the normal point. For some time after this, often 
two or three weeks, little change can be seen, either in the general symp- 
toms or in the physical signs. Gradually the appetite returns, the child 
is brighter and begins to take an interest in its surroundings, the cough 
abates, and little by little the signs in the lungs clear up, and the ea.se 
may go on to complete recovery. Convalescence, however, is always slow, 
and may be interrupted by relapses, it being many months before health 
is fully restored. Although the signs of consolidation disappear in a 
few weeks, rales are apt to persist for a much longer time. It is probable 
in such cases, even though all signs of disease disappear from the chest, 
that the lung does not become quite normal, and relapses and second 
attacks are always possible. The general health may be so undermined 
that the child never regains his former vigour; yet in a surprising 
number of these cases recovery seems to be complete. Protracted 
cases of a mild type are sometimes seen, and, although the temperature 
persists for a number of weeks, it is never high. The course of the 
disease suggests tuberculosis. One such case in a young infant under 
my care was due to a staphylo- 
coccus infection, and was cured 
by vaccines. 

5. Secondary Pneumonia. 
— (a) Complicating Pertussis. — 
It is not often that pneumonia 
develops during the first two 
weeks of this disease. The most 
frequent time is from the third 
to the fifth week, when the pa- 
tient has become exhausted from 
the previous severity of the per- 
tussis. In two-thirds of my 
cases the development of the 
pneumonia was gradual, fol- 
lowing bronchitis of the larger 
tubes. The temperature chart shown in. Fig 
course. 



107° 
106° 
105° 
10i° 
103° 
102° 
101° 
100° 
99° 


1 


2 


3 


i 


5 


6 


7 ) « 


i) 


10 hi 


12 


13 


11 15 16 




























































/ 






























, / 






























/ 




















A 




r 


— »* 


'V 


r^ 






















/ 


J 


-J 
























A 


J 


V 






















/ 


\ 


/ 




















98° 






A-v 




J 


\ 
















. 





Fig. 85. — Temperature Curve of Fatal 
Broncho-pneumonia, Complicating Per- 
tussis. History. — Male, six months old; 
delicate; pertussis for three weeks. Early 
signs of bronchitis of large tubes only; on 
the eleventh day signs of consolidation in 
right upper lobe. Increasing prostration, 
cyanosis, and death. Autopsy. — Large 
areas of consolidation in right middle and 
upper lobes, small scattered spots through- 
out left lung. 



85 well illustrates this 



512 DISEASES OF THE RESPIRATORY SYSTEM. 

When the onset IS sudden, the symptoms do not differ essentially from 
those o( primary pneumonia. The temperature of pertussis-pneumonia 
is usually not high, in a very large number of cases not rising above 
103.5° P., and ranging most of the time from 101° to 108° F. These 
cases are very apt to lie prolonged, the fever often lasting for three or 
four, and sometimes even for six, weeks. The physical signs of consoli- 
dation may persist for a long time after the temperature has become 
normal, and yet the case may recover entirely. I have seen one case in 
which complete recovery occurred after the signs of consolidation had 
persisted for six months, and another in which they had persisted for 
over eight months. Very often the signs continue during the entire 
attack of pertussis. Cerebral symptoms are common, especially toward 
the close of the disease. Of fifty-four fatal cases, twenty-five had con- 
vulsions, and in twenty-two this was the mode of death. Only one case 
which developed convulsions recovered. 

(b) Complicating Measles. — In a small number of cases the pneu- 
monia begins simultaneously with the invasion of measles, but generally 
not until the eruption appears. Instead of gradually falling to normal 
with the fading of the eruption, the temperature continues high. Any 
of the clinical types of primary pneumonia may occur in measles, 
the acute congestive variety, which is fatal in two or three days, 
being especially common. In its course and duration the pneumonia 
of measles resembles the severe form of primary pneumonia. The 
broncho-pneumonia of scarlet fever differs in no way from that of 
measles. 

(c) Complicating Diphtheria. — In many cases this does not give a 
distinct clinical picture of its own, its symptoms being mingled with 
those of diphtheritic bronchitis, with which it is frequently associated. 
In others the forms resemble those seen in measles. The majority of 
cases occur as a complication of diphtheria of the larynx, although it is 
not infrequent in the septic cases in which only the upper air passages are 
involved. Pneumonia after laryngitis may develop within two days 
from the beginning of laryngeal symptoms, and run a rapid course; or 
it may come as late as the second or third week. In a child wearing a 
tube, the diagnosis of pneumonia presents difficulties, owing to the 
alteration in the respiratory sounds and the existence of the loud 
tracheal rales which obscure the usual auscultatory signs. Although 
pneumonia may be apparent by symptoms, its situation may be 
difficult to determine. The most important signs for diagnosis are 
the diminished respiratory murmur, localised rales, and dulness on 
percussion. 

(d) Complicating Influenza. — Without doubt many cases usually re- 
garded as primary are really secondary to influenza, particularly when 
that disease is prevalent. While the pneumonia of influenza may differ 



ACUTE BRONCHO-PNEUMONIA. 513 

in no essential points from the primary form, there are types which arc 
quite characteristic. In one variety the cases are of short duration, fre- 
quently lasting but three or four days, but with high and often widely 
fluctuating temperature, the general symptoms being of only moderate 
severity. A second type is a prolonged pneumonia with exacerbations 
and remissions, which may last for two or three months. A third form 
is the recurrent type of pneumonia, of which a child will sometimes have 
three or four attacks in a single season, separated by several weeks in 
which a moderate cough and a few coarse rales in the chest are the only 
signs of disease. 

(e) Complicating Ileo-colitis. — This is usually a somewhat subacute 
form of pneumonia which is scarcely recognisable except by the physical 
signs. It is seen in the protracted cases of ileo-colitis, usually the ulcera- 
tive variety, and occurs late in its course. Very often pneumonia is not 
suspected during life, the constitutional symptoms being sufficiently ex- 
plained by the intestinal lesions, although the autopsy discloses the fact 
that death was due in part to pneumonia. 

Complications. — Most of those relating to the lungs have been de- 
scribed with the lesions. Pleurisy will be separately considered. Pul- 
monary emphysema is always present to a greater or less degree, but 
can not be made out by physical signs. In very rare instances subcutane- 
ous emphysema has been seen. Abscess and gangrene can seldom be 
recognised by physical signs. Pneumothorax occurs even in infancy, but 
is very infrequent. Otitis is exceedingly common, and one should be 
constantly on the lookout for it. It is recognised only by examination 
of the ear with a speculum. 

Meningitis may complicate acute broncho-pneumonia. It has oc- 
curred in about two per cent of my cases. It is in all respects similar to 
that occurring with lobar pneumonia. Meningeal haemorrhage I have 
seen only once, and was the cause of death in a patient eleven months 
old, who a few days before was seized with convulsions, followed by a 
gradually increasing stupor, which continued until death. The haemor- 
rhage covered the entire convexity of the brain. Endocarditis is ex- 
tremely rare; it was not observed in any of my cases. Acute pericarditis 
is also rare, and when it occurs it is usually with pneumonia of the left 
side. Complications referable to the digestive tract are quite common. 
Herpetic stomatitis is frequent, and occasionally the ulcerative variety 
is seen. Thrush often occurs in the protracted cases among very young 
infants. Gastro-enteritis is not very common, considering the frequency 
.of vomiting and diarrhoea, these depending usually upon functional de- 
rangement. In only three of my cases was there nephritis. In all it 
was of the acute exudative variety, and in only one case was it severe 
enough to affect the prognosis. 

Old lesions of tuberculosis — cheesy nodules in the lungs and some- 
34 



514 DISEASES OF THE RESPIRATORY SYSTEM. 

times in the pleura — are not infrequently met with in patients dying of 
acute pneumonia of a non-tuberculous character. 

Diagnosis. — An acute onset with continuous high fever, rapid respira- 
tion, and cough, should always lead one to suspect pneumonia. When 
to these symptoms are added prostration and a leucocytosis, the diag- 
nosis of pneumonia is almost certain. Cases of the acute congestive type 
are the ones most frequently unrecognised, and in many of these cases 
a positive diagnosis is impossible during life. Many atypical cases of 
pneumonia are seen, particularly in young infants. An unusual tem- 
perature course is perhaps the symptom most likely to lead to a mistake. 
While this, as a rule, is high and remittent, it is sometimes not so, and 
may be but little above normal. Rapid respiration is almost always 
present, but cough may be very slight, especially in infants. In very 
young infants, the diagnosis often rests upon the prostration, cyanosis, 
and rapid respiration, the other acute inflammatory symptoms being 
absent. Only the physical signs of the disease can positively settle the 
question of diagnosis. 

When pneumonia follows bronchitis of the large tubes, whether the 
bronchitis is primary or complicates one of the infectious diseases, the 
extension of the disease to the lungs is usually marked by three symp- 
toms — a steadily rising temperature, more frequent respiration, and in- 
creasing prostration. It may be twelve or twenty-four hours before the 
change is indicated by the physical signs. 

The diagnosis of broncho-pneumonia from congenital atelectasis has 
to be considered only during the first three or four months of life, it 
being rare for atelectasis to give symptoms after this time. In early in- 
fancy the danger of confusing the two is increased by the fact that atelec- 
tasis and broncho-pneumonia may be associated. If the infant has been 
strong and well for the first two months, congenital atelectasis can be 
excluded. It is likely to be found in delicate infants, where there is a 
history of difficulty in resuscitation at birth and feeble cry during the 
early days of life. The temperature is low, often subnormal, the cyanosis 
is out of proportion to the other symptoms, and the physical signs are 
doubtful or absent. 

At the outset, pneumonia can not be positively diagnosticated from 
severe bronchitis. Such a bronchitis often begins with severe pulmonary 
symptoms and a temperature of 103° or 104° F. ; but this high tempera- 
ture is of short duration, usually falling after twenty-four or forty-eight 
hours to 100° or 101° F. The prostration is much less and all the 
symptoms, possibly excepting the cough, less severe. The only physical 
signs are coarse rales, which are heard throughout the chest. 

The same rules apply to bronchitis of the smaller tubes. The rales 
are heard both in front and behind, and usually over both sides. If with 
such rales the temperature continues to rise for three days in succession 



ACUTE BRONCHO-PNEUMONIA. 



515 



above 103° F., it may be assumed that pneumonia is present, provided 
there is no other disease which might explain the temperature. If, in- 
stead of being generalised, the signs of bronchitis are limited to a single 
lung, or to one lung posteriorly, the existence of broncho-pneumonia 
may be regarded as certain. Localised bronchitis, then, is always to be 
interpreted as broncho-pneumonia, provided tuberculosis can be ex- 
cluded. In doubtful cases the chances largely favour broncho-pneumonia 
rather than bronchitis. Attention is again called to the fact already 
mentioned, that there are a large number of cases of pneumonia without 
signs of consolidation. 

The differential diagnosis of broncho-pneumonia from lobar pneu- 
monia will be considered in connection with the latter disease. On 
account of the remittent temperature, broncho-pneumonia may be con- 
founded with malarial fever ; or malaria may be suspected as a complica- 
tion. An examination of the blood will remove the doubt. 

Both the acute and the persistent forms of simple broncho-pneumonia 
may be confounded with the tuberculous form ; the points of distinction 
are considered in the chapter on Tuberculosis. 

Prognosis. — Broncho-pneumonia is always a serious disease, and in an 
infant dangerous to life. The prognosis depends upon the age, sur- 
roundings, and previous condition of the patient, upon the nature of the 
infection, whether the disease is primary or secondary, and, if the latter, 
upon the character of the primary disease. In private practice the mor- 
tality from broncho-pneumonia is from ten to twenty per cent, depend- 
ing upon the conditions mentioned. One whose knowledge of broncho- 
pneumonia is derived from observations in private practice can, however, 
form but little idea of the frequency and severity of this disease in hos- 
pitals and asylums for infants and young children, particularly when it 
occurs with epidemics of measles, diphtheria, and pertussis. The statis- 
tics in the following table are taken from the records of two institutions 
with which I was at the time connected, and fairly represent the re- 
sults seen in such places in children under three years : 



Forms of Pneumonia. 


Cases. 


Deaths. 


Percentage 
mortality. 


Primary broncho-pneumonia 

Following bronchitis of the large tubes 
Secondary to measles 


194 

29 

89 

66 

7 

47 

19 

6 

2 

2 


96 
19 
56 
54 

7 
47 
18 

1 
2 


49.4 
65.5 
62.9 


" " pertussis 

" " scarlet fever 


81.8 
100.0 


" " diphtheria 

" " ileo-colitis 

" " epidemic influenza 

" varicella 

" " erysipelas 


100.0 
94.7 
16.6 

100.0 
100.0 


Totals 


461 


302 









516 



DISEASES OF THE RESPIRATORY SYSTEM. 



The mortality varies with the age of the patient, being highest dur- 
ing the first year, and diminishing steadily thereafter, as shown by the 
following table giving the result in 346 cases: 



Age. 



During the first year . 
" second year 
" third " " 
" fourth " 
" fifth 




Percentage 
mortality. 



66 
55 
33 
16 



In this table are included no cases secondary to measles, scarlet fever, 
or diphtheria. 

Probably the best of all guides to the nature and severity of the in- 
fection is the temperature. An excessively high temperature usually 
indicates a severe type of infection. Some idea of this may be gained 
from these figures, giving the highest temperature and the mortality in 
two hundred and thirty-one cases, not including cases with measles or 
diphtheria : 



Highest Temperature. 


Cases. 


Deaths. 


Percentage 
mortality. 


106° F. or over 


55 
94 
53 
22 

7 


47 
56 
26 
13 
5 


85.5 


105° or 105.5° F 


60.0 


104° or 104.5° F. . . 


49.0 


102° to 103.5° F 


60.0 


99.5° to 101.5° F 


71.0 







The high mortality of the cases with unusually low temperature is 
due to the fact that they nearly always were seen in infants with very 
feeble vitality. The outlook in cases with a steadily high temperature — 
between 102.5° and 104° F. — is usually more favourable than in those 
with wide fluctuations, such as 100° to 105.5° F. As a rule, the danger 
from the disease increases steadily with every degree of temperature 
above 104.5° F. 

An important factor in the prognosis is the previous condition of the 
patient. The association with rickets is unfavourable, both on account 
of the feeble muscular power of these children and their thoracic de- 
formities. Marked and persistent tympanites is always an unfavourable 
symptom. Any condition which diminishes the general vitality increases 
the danger from broncho-pneumonia. As a rule, second attacks are 
more serious than the primary ones, especially if the interval between 
them is short. 

In making the prognosis in any given case, the symptoms to be con- 



ACUTE BRONCHO-PNEUMONIA. 517 

sidered are the height and course of the temperature, the presence or 
absence of nervous symptoms, the condition of the organs of digestion, 

the presence of cyanosis and the extent of the disease as shown by the 
physical signs. I have not found the examination of the blood to aid 
much in prognosis. 

Nervous symptoms early in the disease do not affect the prognosis. 
Three cases in which convulsions occurred at the onset recovered, but 
of thirty-seven cases in which convulsions occurred at a late period dur- 
ing the course of the disease, all but one proved fatal. 

So long as the nutrition of the patient can be well maintained, no 
protracted case is hopeless, no matter how extensive the local disease 
may be; but the existence of vomiting, diarrhoea, or persistent tym- 
panites makes the issue doubtful, even- though the other symptoms are 
favourable. 

Treatment. — The most important part of prophylaxis is to give care- 
ful and early attention to every attack of bronchitis in an infant, for 
every such attack should be regarded as a possible precursor of pneu- 
monia. It is striking that one sees broncho-pneumonia so seldom in 
private practice among the better classes, even though bronchitis is very 
frequent; while among hospital and dispensary patients, where bron- 
chitis is very often neglected, broncho-pneumonia is constantly seen. Cases 
of measles and diphtheria which are complicated by pneumonia should, 
if possible, be carefully isolated from others, and wards in which they 
are treated should be thoroughly disinfected before they are used for 
simple cases. 

The hygienic treatment of broncho-pneumonia is important, and 
usually it receives too little attention. It is much the same as that of 
cases of acute bronchitis already discussed. What was said in that con- 
nection regarding the necessity for fresh air and the caution as to very 
cold air, may be here repeated. The cold-air treatment is not admis- 
sible in very young or delicate infants, nor in cases of disseminated 
pneumonia (capillary bronchitis). The best results from this treat- 
ment are seen in the cases with extensive consolidation and with the 
minimum amount of bronchitis, and it is to be highly recommended in 
the pneumonia of the severe acute infections — diphtheria, measles, and 
scarlet fever. The dress and protection of the patient with the cold -air 
treatment are discussed under Lobar Pneumonia. 

Older children with pneumonia should be kept in bed. Infants for 
a considerable part of the time may be held in the nurse's arms. A fre- 
quent change of position in all cases is essential; no child should be 
allowed to lie for hours directly on the back. The general rules pre- 
viously laid down for feeding all sick children should be followed here. 
As a rule, medicine should not be administered in the food. 

The same local treatment may be employed as in cases of bronchitis. 



518 DISEASES OF THE RESPIRATORY SYSTEM. 

Counter-irritation, best by means of the mustard paste, may be em- 
ployed from three to six times daily. It is of the greatest value in the 
early stage of acute pulmonary congestion, and during attacks of cardiac 
or respiratory failure. The oiled-silk jacket may be applied with advan- 
tage in some cases in infants with low temperature, but should not be 
used when the temperature is high, as it interferes with the means em- 
ployed for its reduction. Poultices should not be used at all. 

Alcohol is usually needed in pneumonia secondary to diphtheria, 
measles, or scarlet fever, also in many primary cases. Its use has been 
greatly abused in this disease. Although there is little doubt that it is 
at times of much benefit, there is considerable doubt as to its mode of 
action. The dose is to be regulated by the condition of the patient. Not 
over one-half ounce daily should be given to an infant of one year. 

Of the circulatory stimulants, caffein, camphor, digitalis, and strych- 
nine may be used, and are recommended in the order named. 

For a child of one year the following doses are suitable : Caffein, gr. 
■£ to gr. J every three hours; camphor is especially valuable for quick 
effect ; Tl\ ij or iij of a ten-per-cent solution in oil may be given hypoder- 
mically ; digitalis, the fluid extract is generally to be preferred as more 
reliable than the tincture, TTt \ may be given every four hours ; strychnine, 
g r - To o" to gr. y^jj every three hours. For immediate effect in sudden 
heart or respiratory failure, nothing compares with adrenalin given hypo- 
dermically — doses T1X ij to TIX v of a 1-1,000 solution ; atrophine, also used 
hypodermically, is sometimes useful — dose, gr. -^. Oxygen may be 
given continuously, but always mixed with atmospheric air. It some- 
times seems to benefit greatly cases with marked cyanosis; often it does 
no good. Gentle friction of the chest wall, without disturbing the pa- 
tient, is sometimes useful in stimulating' the respiratory muscles, espe- 
cially in protracted cases. 

It should be remembered that the normal range of temperature in 
broncho-pneumonia is from 101° to 104.5° F. This temperature is not 
in itself exhausting, and the chances of recovery are not, I think, im- 
proved by reducing it so long as it remains within these limits. Too 
much can not be said in condemnation of the practice of giving the 
coal-tar products in full doses for the reduction of temperature. In 
small doses they are often useful to allay nervous irritability, restless- 
ness, and promote sleep. 

Antipyretic measures are indicated in cases of hyperpyrexia, which 
we may define as 105° F. or over, especially when extreme nervous symp- 
toms exist. Under these circumstances, the most certain, the most 
within our control, and hence the safest antipyretic, is cold. It may be 
used by the evaporation bath, the cold pack, sponging, cold compresses, 
or an ice-bag applied to the chest. (See chapter on General Thera- 
peutics.) 



ACUTE BRONCHO-PNEUMONIA. 519 

Not all children bear cold well, and in its use and frequency of repe- 
tition one must be guided by its effect upon the child's genera] condition 
as well as upon the temperature. When with hyperpyrexia we have 
general cyanosis, cold surface, feeble pulse, shallow respiration, and 
stupor, cold is contraindicated and a hot mustard bath should be used. 

Inhalations are of more value in relieving cough and in promoting 
bronchial secretion than any other means we possess. The same sub- 
stances are to be used, and in the same way as mentioned in the article 
on Bronchitis. 

The nervous symptoms, restlessness, loss of sleep, etc., are often best 
controlled by cold or tepid sponging; in other cases by small doses of 
phenacetine — i. e., one grain every three hours to a child of six months. 
Opium is to be avoided unless there is severe pain, which is very rare; 
or when the incessant cough is not relieved by inhalations. Codeine may 
be given in doses of gr. ^ every three or four hours to a child of one 
year, or morphine in half this dose. 

Sudden attacks of general collapse with cyanosis are frequent in 
severe cases of broncho-pneumonia. They may come on at any period in 
the disease. When occurring in the early stage, if promptly and ener- 
getically treated, recovery may take place, but when they come on in the 
late stages they are usually fatal. They may be due to acute congestion 
or oedema of the lung not previously involved, or to circulatory failure, 
the result of vaso-motor paralysis. The most efficient treatment is the 
use of dry cups or the hot mustard bath, the administration of adre- 
nalin and caffein or camphor hypodermically, and to give oxygen con- 
tinuously. 

When the fever continues for five or six weeks, with no disposition 
on the part of the disease to subside, one should continue the sustain- 
ing treatment adopted in the earlier part of the disease — careful feed- 
ing and judicious stimulation, but most of all should these patients be 
given the benefit of the fresh-air treatment. Some apparently hopeless 
cases recover ; but, unfortunately, in the majority the continuance of the 
pneumonic process is in itself evidence of the weakened vitality of the 
patient, and, though he may live a long time, most such attacks ulti- 
mately prove fatal. 

When the fever has disappeared, and there is only a persistence of 
the physical signs and the general cachexia, the cases are more hopeful. 
Here, a change of air is more important than all other means of treat- 
ment. If in the winter or spring the child can be removed to a warm, 
dry climate where he can be kept in the open air, or if, in the summer, 
he can be taken to the mountains, immediate improvement is often Been, 
followed by rapid recovery. This experience we see repeated every year 
with hospital patients when they are transferred from the city to the 
country in May or June. With the change of air a general tonic plan 



520 



DISEASES OF THE RESPIRATORY SYSTEM. 



o( treatment should be followed, cod-liver oil, arsenic, and iron being 
used, according to the indications in each particular case. 

One should never declare one of these cases of protracted pneumonia 
to be hopeless, nor should he be too ready to assume that tuberculosis 
is present because the child is wasted and anaemic, and the physical signs 
have persisted. 

No specific treatment of pneumonia has yet been proposed which can 
be recommended. 



CHAPTER V. 



DISEASES OF THE LUNGS.— (Continued.) 

LOBAR PNEUMONIA. 

(Fibrinous Pneumonia; Croupous Pneumonia.) 

Etiology. — Age. — Lobar pneumonia may occur at any age. I have 
seen it in an infant of three months; but it is not until after the first 
year that it begins to be frequent. After the third year nearly all the 
cases of primary pneumonia are of this variety. 

Of 500 cases the ages were as follows: 



Age. 


Cases. 


Per cent. 


During the first year 


76 
309 
104 

11 


15 


From the second to the sixth year 

" " seventh to the eleventh year 

" " twelfth to the fourteenth year 


62 
21 

2 


Totals 


500 


100 



Season. — In 136 cases the seasonal occurrence was as follows : 



Season. 


Cases. 


Per cent. 


In the three winter months 


48 

62 

6 

20 


35 


" " " spring " 


46 


" " " summer " 


4 


" " " autumn " 


15 






Totals 


136 


100 



Lobar pneumonia, in children therefore, as in adults, occurs most 
frequently during the spring months. April shows the largest number 
of any single month. 

Previous Condition. — In my hospital cases, eighty-two per cent of the 
children were previously in good condition, and only eighteen per cent 



LOBAR PNEI'MOMA. 



52 1 



were delicate, rachitic, or syphilitic. This observation bas been borne out 
by my experience in private practice, viz., thai as a rule lobar pneumonia 
affects children who were previously healthy. Or to stale the matter dif- 
ferently, if a strong child contracts pneumonia it is nearly always of the 
lobar variety. 

Previous Disease. — Previous attacks of pneumonia are observed in but 
a small proportion of cases. It was noted only five times in 160 cases. 
In the vast majority of cases lobar pneumonia is a primary disease, al- 
though it occasionally occurs as a complication of pertussis, measles, 
typhoid or scarlet fever, and even diphtheria — chiefly, however, in chil- 
dren over three years old. 

Epidemics of lobar pneumonia I have never witnessed, although on 
several occasions I have seen two children in a family attacked either 
simultaneously or in rapid succession. Exhaustion, fatigue, and exposure 
are to be ranked as associated exciting causes. 

In addition to other causes, there is required for the production of 
the disease the presence and growth of the pneumococcus. Associated 
with it are often found the staphylococcus aureus and occasionally the 
bacillus of influenza. 

Lesions. — The Seat of the Disease. — In 950 cases in children under 
fourteen years, this was as follows: 



Seat of Disease. 


Personal Collected 
cases. cases. 


Totals. 


Right lung, upper lobe only 


39 

8 

26 

13 


137 

4 

142 

64 


176 


" " middle " " 


12 


" lower " " . . . 


168 


" more than one lobe 


77 


Totals, right lung 


86 347 


433 






Left lung, upper lobe only 


25 

49 

9 


68 

214 

29 


93 


" lower " " 


263 


" " more than one lobe 


38 










Totals, left lung 


83 311 


394 






Both lungs, upper lobes 


3 


13 
38 


13 


" lower " 


41 


" elsewhere 


9 


60 


69 










Totals, both lungs 


12 


111 


123 











The right lung was thus affected in 45.5 per cent; the left lung in 
41.5 per cent; both lungs in 13 per cent. In the order of frequency, the 
disease involves, first, the left base; second, the right apex; third, the 
right base; forth, the left apex. The disease affects, as a rule, a single 
lobe, and often only a circumscribed portion of a lobe. 



522 DISEASES OF THE RESPIRATORY SYSTEM. 

Lobar pneumonia among children is bo rarely fatal that the oppor- 
tunities for a study of the peculiarities of the lesion have been some- 
what limited. The anatomical changes resemble those seen in the adult 
lung. There is an exudation into the alveoli and smaller bronehi of 
fibrin, serum, leucocytes, and red blood-cells (Fig. 71). There is usually 
in addition an inflammation of the mucous membrane of the larger 
bronchi and of the pleura. The frequency and severity of the pleurisy is 
a peculiarity of the lesion in children. 

In the first stage, that of congestion, the portion of lung involved is 
dark-coloured, heavy, and cedematous, and shows under the microscope a 
serous and cellular exudation into the air vesicles, with swelling of the 
epithelial cells lining the alveoli. 

In the second stage, that of red hepatisation, there is usually some 
exudation upon the pulmonary pleura, generally a thin layer of fibrin, 
giving it a dull, granular look. The lung itself is of a uniform dark-red 
colour. It is solid and cuts like liver. It looks as if it had been inflated 
to its utmost extent and then injected with a material which had solid- 
ified. The consolidated area is sharply defined. Under the microscope 
the air vesicles are seen to be distended with an exudation which is 
chiefly fibrin, but with some leucocytes, red blood-cells, and desquamated 
epithelial cells. The cells are chiefly leucocytes, and are usually more 
abundant than in the pneumonia of adults. 

In the third stage, that of gray hepatisation, the lung is more moist, 
and the inflammatory products are partly decolourised. This change 
takes place irregularly throughout the lung, giving it a mottled appear- 
ance. 

The fourth stage, that of resolution, follows gray hepatisation, and 
consists in the degeneration and liquefaction of the products of inflam- 
mation, which are ultimately carried away by the lymphatics, or pushed 
out into the bronchi and removed by coughing. 

The duration of the stage of congestion is from a few hours to sev- 
eral days; that of the stage of red hepatisation from two days to two 
£>T three weeks. This is the condition in which the lung is most often 
seen at autopsy. The stage of gray hepatisation is commonly shorter. 
Resolution usually begins when the temperature falls to normal, but 
occasionally it may be delayed for several days. It is generally complete 
in about a week. 

Variations in the Lesions. — (1) Instead of clearing up at the usual 
time, the lung may remain consolidated for several weeks, and then re- 
solve. (2) The stage of gray hepatisation may be followed by a great 
exudation of pus cells, which may everywhere infiltrate the affected lung; 
or these may be circumscribed so as to form a single large abscess or 
many small ones. (3) There may be small areas of gangrene. All these 
conditions are very rare in children. (4) There may be excessive pleu- 



LOBAR PNEUMONIA. 523 

risy, or pleuropneumonia. This is found at autopsy in about one-half 
the cases, and will be separately considered elsewhere. 

The lesions in the other organs are for the most part due to the pneu- 
mococcus. There may be pericarditis, especially with pneumonia of tin- 
left side, if complicated by excessive pleurisy. This is seen even in in- 
fants. The pericardial inflammation closely resembles thai of the pleura. 
There is a very abundant exudation of fibrin and pus, coating both Bur- 
faces of the pericardium. Acute meningitis is rather rare. It is an 
acute purulent inflammation, with a very abundant exudation of green- 
ish-yellow fibrin and pus, chiefly at the convexity. Less frequently peri- 
tonitis is present. Acute parotitis and acute arthritis are seen as rare 
complications of pneumonia. In most of the complicated cases the other 
lesions are second to those in the lungs ; but they may begin simultaneously 
with, or even precede, the pneumonia. In cases with complications other 
than thoracic ones, a general pneumococcus septicaemia is usually pres- 
ent. From reports thus far published it would appear that pneumococci 
are found in the blood of children with pneumonia much less frequently 
than in that of adults. In seventy cases examined by Often, positive 
blood cultures were obtained but nine times; while in adults fully half 
the cases give positive results. 

The heart is generally found in diastole, with the cavities, especially 
those of the right side, distended with soft clots. There may be found 
ante-mortem thrombi, which may extend into the pulmonary artery or 
the aorta. 

Symptoms. — (1) The Typical Course. — A child three or four years of 
age, after a few hours of slight indisposition, is suddenly taken with 
vomiting, followed by a rapid rise in temperature. He is dull and heavy, 
complains of headache and general weakness, refuses food, and is easily 
persuaded to remain in bed. He has the appearance of being quite ill, 
even after a few hours. Occasionally sharp pain in the side is complained 
of. The skin is dry ; there are marked thirst, restlessness, and the other 
symptoms which accompany fever. The temperature is found to be 104° 
F., or even higher; the respirations 40 to 50 a minute; the pulse full,* 
strong, and 120 to 130. On the second day the patient is no better. 
The temperature remains high; the tongue is coated; the anorexia 
continues; the pain is more severe; cough is present and may be quite 
frequent. 

After the second or third day the patient is usually more comfortable, 
and sleeps better, but may be disturbed by the cough. At times there 
is restlessness, and at night there may even be slight delirium. The 
respiration continues rapid and the temperature high. These general 
symptoms show very little change until the sixth or seventh day, when, 
after a long sleep, which has been more natural than before, the patienl 
wakes, decidedly improved as to all his symptoms. There is less fever, 



521 DISEASES OV THE RESPIRATORY SYSTEM. 

and the temperature continues to fall rapidly until it touches the normal 
line, or it may even go below this. As the fever subsides the pulse drops 
to 90 or 100, and the respirations to 25 or 30 a minute. The appetite 
soon returns, and convalescence is usually rapid. In a week the patient 
is out of bed, and in two or three weeks more he is out of doors. This 
is the ton rso seen in fully two-thirds of all the cases of lobar pneumonia 
at tli is age. 

(2) Pneumonia of Short Duration. — Instead of running the usual 
course of from five to eight days, cases are seen in which the duration is 
only three or four days, although the physical signs indicate that the 
process in the lung passes through the usual stages. These differ from 
the ordinary type chiefly in their duration. They are always mild. 

(3) Abortive Pneumonia. — This form of the disease is rarely seen 
in hospitals, but it is not infrequent in private practice where the phy- 
sician is summoned at the earliest signs of illness. The onset is precisely 
like that of ordinary pneumonia, and may even be as severe as the aver- 
age case. The physical examination of the chest gives all the signs of 
the first stage of the disease, but on the second or third day the physician 
is greatly surprised to find that the temperature has fallen to normal, 
and that all the physical signs have disappeared. The process in such 
cases does not seem to go beyond the first stage of congestion; there is 
no evidence of hepatisation of the lung. The course is often such as to 
lead the physician to the opinion that he has made a mistake in his 
diagnosis. This type of pneumonia corresponds with abortive types of 
other infectious diseases so frequently met with in children. The tem- 
perature curve in such a case is shown in Fig. 89. The diagnosis of 
these cases is always attended with some uncertainty. There can be no 
doubt that many of the unexplained high temperatures of brief duration 
which are seen in children are from this cause. Exactly why it is that 
the disease sometimes terminates in this way can not always be explained. 
It may be because the resistance of the patient is greater than usual, or 
the virulence of the pneumococcus is less. 

(4) The Prolonged Course. — Although usually lasting about a week, 
it is not rare for pneumonia to continue ten, twelve, or even fifteen days. 
This prolonged course is usually due to the fact that the disease spreads 
from one part of the lung to another, or even to the opposite lung, in- 
volving in succession two, three, or more lobes. This is sometimes known 
as " creeping " pneumonia ; it is always severe and the outlook is gen- 
erally unfavourable. A prolonged temperature with physical signs lim- 
ited to a single lobe should always suggest complications, most frequently 
empyema, occasionally pericarditis. 

(5) Cerebral Pneumonia. — This term was first applied by Rilliet 
and Barthez to cases of pneumonia in which the cerebral symptoms pre- 
dominate. They will be considered later. 



LOBAH l'NElMONIA. 



.)_'.) 



Onset. — Prodromal symptoms of more khan a few hours" duration are 
quite rare. The onset of lobar pneumonia is almost invariably abrupt, 
with well-marked symptoms — vomiting, diarrhoea, chill, or convulsions. 
Vomiting is altogether the most frequently seen. In summer partic- 
ularly, there may be vomiting and diarrhoea. A distinct chill is rare in 
a child under five years of age, and is not very common even in older 
children. Convulsions are not very infrequent, being seen in about five 
per cent of the cases. Their occurrence depends upon the suddenness of 
the invasion and the susceptibility of the patient. 

Cough. — This is present in most of the cases throughout the disease, 
but often is not marked for the first day or two. It is seldom a distress- 
ing symptom. A disposition to suppress the cough on account of pain is 
very frequently noticed. 

Expectoration. — This is rarely seen in early childhood, and practically 
never under five years of age. Children of ten or twelve may have the 
same expectoration as adults — white and viscid, or brownish-red early 
in the disease, yellow and abundant toward its close. This shows the 
presence of the pneumococcus in great numbers. 

Pain. — Headache and general muscular pains in the back and ex- 
tremities are frequent during the invasion. The characteristic pain, how- 
ever, is pleuritic. It is not necessarily felt in the region of the affected 
lung, and often not in the chest at all. It is frequently referred to the 
loin, the epigastrium, or to any region to which the intercostal nerves 
are distributed. I have seen a number of cases in which there was intense 
localised pain in the right iliac fossa, associated with such extreme 
tenderness as to lead to the suspicion that the case was one of appen- 
dicitis. 

Prostration. — This is one of the characteristic features of pneumonia. 
The patient is generally willing to go to bed on the first day of the 
attack, and shows little desire to leave it while the disease continues. 
" Walking cases " are not common in children. 

Respiration. — This is always accelerated, and generally out of propor- 
tion to the pulse. The normal ratio of the respiration to the pulse is one 
to four; in pneumonia, frequently one to two. The respiration is not 
laboured and not quite panting, although this term is sometimes used 
to describe it. It is jerky. There is a short inspiration, then a momen- 
tary pause, followed by a quick expiration, which is accompanied by a 
short moan. This expiratory moan is very characteristic. The rapidity 
of respiration is usually in proportion to the amount of lung involved, 
but it is also modified by the temperature, as the respirations often drop 
from 60 to 30 in the course of a few hours at the crisis. 

Pulse. — In the early part of the disease this is frequent, full, and 
strong, from 120 to 150 a minute. Later it may be weak, small, com- 
pressible, and sometimes irregular. It is much more rapid in the child 



526 



DISEASES OF THK RESPIRATORY SYSTEM. 



than in the adult. 160 and 180 being often seen in cases not especially 
severe. The pulse rate is of less importance than its character. 

Temperature. — The typical temperature curve of lobar pneumonia 
(Fig. 86) is characterised by an abrupt rise usually to 104° or 105° F., 
and by daily fluctuations generally within the limits of two or three 



105° 1 1 2 1 8 1 * 1 5 ! 6 7 8 


:• Fi 


101° r MH 


(>./ 


98°I H 



Fig. 86. — Typical Tempera- 
ture Curve of Lobar Pneu- 
monia. History. — Male, 
three years old; in fair con- 
dition; sudden onset; signs of 
consolidation — bronchial res- 
piration and voice, and dul- 
ness — over left lower lobe be- 
hind, not distinct until the 
morning of the fifth day. On 
the seventh day the lung was 
resolving. 



107° 


1 


2 


s 


i 


5 


6 


7 


8 





10 


11 


12 13 14 


15 


10 


17 


18 


19 


20 


106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 


























































K 






















/ 


A 




A 


A 


A 


J\ 


ft 


t 
















\ 




J 




A 




1 


I 


I 




\ 


' / 


f | 
















/ 








' 




i 






\ 


/ 


















V 






/ 








I 




I 


s ' 




i 






















V 




















































I 














98° 
97° 




























V 


/ 




































V 




V 









Fig. 87. — Lobar Pneumonia with Remittent Tem- 
perature. History. — Female, eighteen months old; 
in fair condition ; sudden onset; repeated examina- 
tions of chest made, but no abnormal signs until the 
ninth day, when there were very rude respiration 
and slight dulness at the right apex, in front; on the 
twelfth day all the signs of consolidation at the same 
point, no rales; four days after the crisis the lungs 
were clear. 



degrees until the crisis, at which time the temperature falls to normal, 
usually in the course of twenty-four hours. After this time it does not 
go above the normal line. Such a curve is seen in the majority of cases 

over three years of age. 

In cases under three 
years of age it is not un- 
common for the temper- 
ature to be of a more or 
less remittent type (Fig. 
87). 

These wide fluctua- 
tions often lead to great 
difficulty in diagnosis, 
particularly if the physi- 
cal signs appear late, as 
they not infrequently do. 
It is probable that some 
of them are to be ex- 
plained as mixed infec- 
tions. 

The accompanying 
chart (Fig. 88) illustrates three features which are often seen in pneumo- 
nia: (1) A temperature which early in the disease is steadily high and as 



107° 


1 


2 


8 


1 


5 


6 


7 


8 | 9 10 


11 12 1 


i 14 


15 


16 


17 


18 


19 


20 


106° 
105° 
101° 
103° 
102° 
101° 
100° 
99° 


















/I 
































A 


L 




















A 








1 1~ 


A 


J\ 


U 


1 
















/ 


M 


f 


\ 




\ 




' 




N 
















/ 




V 


v^ 


\ 


v 








J 
































" 




































y 




















• 














1 
















98° 
97 o 

96° 
95° 
91° 






















1 , 


A 


IS 


A 




























u 


A 


sT 
































/ 
































N 

















































Fig. 88. — Lobar Pneumonia with Subnormal Tem- 
perature after the Crisis. History. — Female, 
nineteen months old; fairly healthy; sudden onset; 
symptoms typical but physical signs delayed; con- 
solidation in left mammary region on the eighth day; 
on the ninth in right lung middle lobe; on the elev- 
enth day a pseudo-critical drop followed after twenty- 
four hours of apyrexia by a further rise, which was 
accompanied by signs of extension of the disease in 
the right lung. Resolution rapid after crisis. 



LOBAR PNEUMONIA. 



527 



106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 




1 


! 8 


i 


5 ( 


1 


8 


9 


10 


11 


12 


is In 


15 


10 


17 












y 


A 




























/ 


\ 


V \, 


J 


























V 






\ 


















-v 












V 


u 
















\f 






1 










A 


































\. 
















L, 




J 
























98° 



































the day of crisis approaches becomes remittent; (2) a secondary 

after being normal for twenty-four hours, which was due in this in- 
stance to an extension of the disease to a new pari of the Lung; (3) a 
fall to a point considerably below normal at the time of the crisis. In 
this case the temperature fell in the course of eighteen hours from 105° 
to 95° F., and later still 
lower ; it was two days before 
it finally remained at the 
normal point. A fall to 
96.5° or 97° F. at the time 
of crisis is not uncommon. 

In the foregoing cases the 
fever terminated by crisis. 
In Fig. 89 is shown one end- 
ing by lysis. This is a mode 
of termination much more 
frequent in young children 
than in those who are older. 
Thus, in 93 of my own cases, 
nearly all of which were un- 
der three years of age, the 
fever ended by crisis in 49, 
and by lysis in 44; while in 

552 collected cases, the majority of which were in older children, 396 
ended by crisis, and 126 by lysis. 

The following table shows the day of crisis in 567 cases of lobar 
pneumonia in children who recovered: 



Fig. 89. — Abortive Pneumonia in Left Lung, 
followed by typical pneumonia in rlght 
Lung, Terminating by Lysis. History. — 
Male, seventeen months old, healthy; sudden 
onset; on the second day disseminated fine rales 
in both lungs behind, and over left lower lobe 
very feeble respiration, high-pitched — i. e., some 
bronchitis, with congestion (?) of left base. On 
the third, fourth, and fifth days, general symp- 
toms gone and signs nearly disappeared. On 
the sixth day all symptoms of pneumonia, and 
on the seventh distinct consolidation of right 
base, rest of chest clear. Subsequent course 
typical ; resolution rapid and complete. 



The Day of Crisis. 



Third " 


22 


Fourth " 


43 


Fifth " 


88 


Sixth " . 


83 


Seventh " 

Eighth " 


132 

73 


Ninth " 


55 


Tenth " 


22 



Eleventh day 18 

Twelfth " 7 

Thirteenth day 8 " 

Fourteenth " 7 " 

Fifteenth " 1 case. 

Eighteenth " 3 cases. 

Twenty-first day 1 case. 

Twenty-sixth " 1 

567 



From this table it will be seen that the most frequent critical day is 
the seventh, and that in sixty-six per cent of the cases it was from the 
fifth to the eighth day. The causes of a post-critical rise in the tempera- 
ture are chiefly two — extension of the disease to a new area, or the devel- 
opment of pleurisy, which is apt to be purulent. Less frequently it is 
due to otitis, meningitis, pericarditis, or gastro-enteritis. In fatal casts 



528 DISEASES OF THE RESPIRATORY SYSTEM. 

the temperature is generally high until the end. In general, it may be 
said that the temperature is considerably higher in children than in 
adults; in the majority of cases it roaches 105° F., the usual range being 
from 102° to 105° F. In 15 of 137 cases, or eleven per cent, it reached 
106° F. or over. 

Gastro-entcric Symptoms. — These are more common in infants than 
in older children. At the onset there is frequently vomiting, some- 
times also diarrhoea. A continuance of the vomiting is rare, and is 
generally due to improper feeding or medication. It may be a very 
serious complication. Diarrhoea is also rare, except at the onset and 
in summer cases. Great tympanites is a distressing symptom, and 
when present, it is a bad prognostic sign. Throughout the disease 
there are anorexia, coated tongue, and the usual symptoms of high 
fever. 

Nervous Symptoms. — Cerebral symptoms are frequent and very often 
misleading. Pneumonia is often ushered in by convulsions, which may 
be repeated two or three times in the course of the first twenty-four 
hours. They are sometimes followed by drowsiness or stupor, sometimes 
by active delirium. Cerebral symptoms may predominate for several 
days. There may be opisthotonus, dilated or contracted pupils, irregular 
pulse, retracted abdomen, and, in fact, almost every symptom of menin- 
gitis. Lumbar puncture in these cases usually shows an excess of cerebro- 
spinal fluid under high tension and it may contain a few pneumococci. 
Occasionally the decubitus en chien de fusil, or gun-hammer position, is 
assumed. These are often described as cases of cerebral pneumonia, and 
in many of them pneumonia is not suspected until the fourth or fifth 
day of the disease, sometimes not until the crisis occurs, when the rapid 
disappearance of all these nervous symptoms indicates their origin. 
Early convulsions are not generally followed by an especially severe type 
of the disease, only one of seven such cases proving fatal. On the other 
hand, cases with late convulsions are usually fatal, as they indicate either 
a very severe form of the disease or the development of a serious compli- 
cation, usually meningitis. 

Delirium is much more frequent than convulsions, and is seen in 
nearly one-fourth of the cases. Generally it is slight and noticed only 
at night or when the temperature is very high. It is most pronounced 
at the height of the disease. Other nervous symptoms belonging to the 
typhoid state are occasionally seen, but only in the worst forms of the 
disease. 

I have been unable to discover any relation between the seat of the 
disease in the lungs and the occurrence of cerebral symptoms. They 
are more frequent in children under five years than in those who 
are older, and depend upon the suddenness of the invasion, the in- 
tensity of the infection, and the susceptibility of the child. Late in 



LOBAR PNEUMONIA. 529 

the disease they may indicate exhaustion, toxaemia, or complicating 
meningitis. The usual nervous symptoms — restlessness, headache, sleep- 
lessness, etc. — are nearly always proportionate to the height of the 

temperature. 

Urine. — Throughout the febrile period of the disease the urine is 
scanty, high-coloured, with a high specific gravity, usually loaded with 
urates and with marked diminution of the ehlorides. In a small number 
of cases a trace of albumin may be found, and occasionally a few hyaline 
casts. Evidences of serious renal disease I have seldom found in lobar 
pneumonia, and in the experience of all observers it is extremely rare in 
early life. 

Skin. — The face, in pneumonia, is usually flushed, sometimes on both 
sides and sometimes only on one; in other cases it is pale, but not in- 
dicative of pain. Cyanosis is rare except toward the close of the disease 
and is usually a sign of respiratory failure. Herpes of the lips or face is 
quite frequent. 

Blood. — There is regularly a leucocytosis of from 20,000 to 50,000; 
the increase is chiefly in the polymorphonuclear cells which usually form 
from seventy to eighty-five per cent of the leucocytes. (See also chapter 
on Diseases of the Blood.) 

Physical Signs. — The earliest signs in pneumonia are due to the 
acute congestion of the affected lung or lobe, in consequence of which 
less air enters this portion and more air the rest of the lungs. Percus- 
sion gives diminished resonance or slight dulness, often of a somewhat 
tympanitic character over the affected area, and exaggerated resonance 
over the remainder of this lung and over the opposite lung. Ausculta- 
tion over the affected lobe gives feeble respiratory murmur, rather high 
in pitch; sometimes there may be absence of all breath-sounds so com- 
plete as to suggest fluid. The normal respiratory murmur over the 
healthy portions of the lungs is intensified. In children this exag- 
gerated breathing is not infrequently mistaken for bronchial breathing, 
and the physician may be led into the error of locating the pneumonia 
upon the wrong side. Exaggerated breathing does not differ from nor- 
mal breathing except in intensity. Bronchial breathing is higher in 
pitch, tubular in character, and is heard with nearly equal intensity, 
both on expiration and inspiration. If the chest is frequently auscul- 
tated, crepitant or fine subcrepitant rales (Figs. 90 and 91 ) may 
usually be heard at some period at the end of full inspiration. hut 
often they are present but for a few hours, and they may \)c missed 
altogether. 

In the second stage, that of consolidation (Fig. 92), no air enters 

the air vesicles of the affected portion of the lung. Upon palpation there 

is found here exaggerated vocal fremitus, and on percussion then- is 

marked dulness, but very rarely flatness. Over the rest of this lung 

35 




Fig. 90. — First Stage. Congestion of left 
lower lobe, with crepitant rales. Feeble 
breathing of a rude character, with slight 
dulness. 



Fig. 91. — In the centre of the area, a small 
spot of pure bronchial breathing and voice; 
surrounding this an occasional crepitant rale, 
with broncho-vesicular breathing and slight 
dulness. 



n 



Fig. 92. — Second Stage. Complete consolidation of left lower lobe. Pure bronchial breathing 
and bronchial voice; marked dulness; increased vocal fremitus, and at the lower part a few 
friction sounds. 

Note. — During resolution the signs take the inverse order: those of Fig. 92 give place to 
those of Fig. 91, and these in turn to those of Fig. 90. In addition, many coarse rales may 
be heard. 

530 



LOBAR PNEUMONIA. 53] 

there is exaggerated, sometimes even tympanitic, resonance; this is espe- 
cially frequent at the apex of the lung in front, when there is consolida- 
tion at the base behind. Under these conditions cracked-pol resonance 
may sometimes be obtained. Over the healthy lung there le ated 

resonance. On auscultation over the consolidated portion there are bron- 
chial breathing and bronchial voice, the area over which they are heard 
being sharply defined. Rales are usually absent, but there may be pleu- 
ritic friction sounds. 

In the stage of resolution there is a gradual disappearance of the 
signs of consolidation. The pure bronchial is replaced by broncho-vesic- 
ular breathing, the vesicular element gradually predominating. Moist 
rales of all varieties are heard. Usually the most persistent signs are 
slight dulness or diminished resonance, with a respiratory murmur which 
is feebler than normal and a little higher in pitch; sometimes there are 
also dry friction sounds. These signs may persist for two or three 
weeks. 

Exceptional Physical Signs. — While in the majority of cases the signs 
of consolidation are distinct on or before the fourth day, in not a few 
they may be delayed much longer. Of eighty-two cases in which the day 
was noted on which consolidation was found, it was not until the fifth 
day or later in one-fourth the number. In six of them, although care- 
fully and repeatedly examined, no consolidation was found until the 
seventh day or later and in one case not until the twelfth day. It has 
been customary to look upon these cases of delayed or concealed physical 
signs as cases of central pneumonia. That pneumonia may exist in the 
centre of a lung for a number of days is, to my mind, extremely improb- 
able. At autopsy, superficial pneumonia I have very frequently seen, 
but central pneumonia never. There are two regions in which pneumonia 
may exist and yet not be accessible by our means of physical examination, 
viz., at the apex of the lung in the part covered by the shoulder, and 
along the posterior border of the lung where it lies against the vertebrae. 
In either of these situations pneumonia may be present without our being 
able to find it. It is quite common in cases with late physical signs that 
the first distinctive evidences of disease are found high in the axilla, or 
beneath the clavicle in front, and these regions should be closely watched 
in doubtful cases. Sometimes the delay is best explained by assuming 
that constitutional symptoms due to a pneumococcus infection may be 
present for several days before the development of the local lesion in 
the lung. 

Complications. — The occurrence of dry pleurisy over the consolidated 
portion of the lung is so constant that it can hardly be considered a com- 
plication. A slight serous exudation of two or three ounces is not un- 
common, but more than this is rare in young children. In the most 
severe cases of pleurisy there is an excessive exudation of fibrin and pus. 



532 PlSl' ASKS OF THE RESPIRATORY SYSTEM. 

This occurred in eight per cenl of my cases. This variety is known clin- 
ically as pleuropneumonia, and will be considered separately. Pericar- 
ditis is uncommon. It is Been more often in infants than in older chil- 
dren. It most frequently develops at the height of the pneumonia and 
occurs rather oftener when this affects the left lung than the right; it 
occurs in pleuro-pneumonia more often than in the simple form. The 
pericarditis is usually of the fibrino-purulent type. It may sometimes 
he discovered by physical signs; hut rarely gives rise to any new symp- 
toms. Endocarditis was not seen in my cases, though it occasionally 
occurs. Meningitis is rare, and generally develops late in the disease. 
It is nearly always ushered in by repeated attacks of vomiting or con- 
vulsions. Its course is short and progressive. Peritonitis causes few new 
symptoms except abdominal distention, pain, and tenderness. Parotitis 
and arthritis arc very rare and are easily recognised. 

Course and Termination. — In the great majority of cases lobar pneu- 
monia terminates either in perfect recovery or in death. When ending 
in recovery, resolution commonly begins immediately upon the cessation 
of the fever, and is complete in about a week. Delayed resolution is not 
common in children; chronic pneumonia and tuberculosis are rare 
sequela?, but empyema is very frequent. Its symptoms sometimes develop 
immediately after the pneumonia, the temperature continuing high; or 
there may be an interval of a few days before the development of the 
pleural symptoms. Some pleuritic adhesions probably remain in every 
case in which there has been much dry pleurisy, and when severe and ex- 
tensive, these may be the cause of subsequent symptoms, like any other 
dry pleurisy. 

Death from uncomplicated pneumonia may be due to exhaustion, or 
to heart failure, with or without failure of the respiration. The signs of 
heart failure sometimes develop quite rapidly in cases which are appar- 
ently doing well. The symptoms are : coldness of the hands and feet, 
then of the legs and arms ; a rapid, compressible, and sometimes irregular 
pulse ; muscular weakness and pallor, but usually no cyanosis. The symp- 
toms of respiratory failure are: very rapid superficial respirations, some- 
times 100 a minute; blueness of the lips and finger nails; often a leaden 
hue of the whole body ; there are loud tracheal rales, and recession of all 
the soft parts of the chest on inspiration. 

Death may occur early in the disease, where the pneumonia has 
spread rapidly, involving both lungs. In most of the uncomplicated 
fatal cases, death results from failure of the circulation at about the end 
of the first week. In the complicated cases death usually occurs in the 
second week; but I once knew fatal meningitis to develop at the end of 
the fourth week. 

Diagnosis. — The most characteristic differences between broncho- and 
lobar pneumonia are shown in the following table : 



LOBAR PNEUMONIA. 



533 



BRONCHO-PNEUMONIA. 

1. Often secondary. 

2. Under two, chiefly under one year. 

3. Occurs more frequently in delicate 
and debilitated children. 

4. Bacteria — in primary cases, usu- 
ally the pneumococcus; in secondary 
cases, usually mixed infection. 

5. Products of inflammation chiefly 
cellular; process often diffuse. 

6. Onset often gradual, sometimes in- 
sidious, especially when secondary. 

7. No typical course; fever often lasts 
three or four weeks; rarely terminates by 
crisis. 

8. Involves both lungs as a rule, most 
frequently lower lobes posteriorly. 

9. Signs of bronchitis mingled with 
those of consolidation; rales in other 
parts of the same lung, or in the opposite 
lung, throughout the disease. 

10. Consolidation later — fourth to 
seventh day: there may be none; apt to 
be incomplete; shades off gradually. 

11. Resolution slow, one week to two 
months; often incomplete; strong tend- 
ency to become chronic. 

12. Relapses and second attacks fre- 
quent. 

13. Sequelae: Empyema, chronic in- 
terstitial pneumonia, sometimes tuber- 
culosis. 

14. Prognosis always serious from the 
age and the circumstances under which 
disease occurs. 

15. Hospital mortality 50 per cent of 
primary cases, 65 per cent of all cases. 



LOBAR PNEUMONIA. 

1. Almost always primary. 

2. Most common between three and 
eight years. 

3. More often in those previously 
healthy. 

4. The pneumococcus, very often 
alone. 

5. Chiefly fibrin; process circum- 
scribed. 

6. Onset sudden, with well-marked 
symptoms. 

7. Typical course; crisis usually from 
fifth to eighth day. 

8. Usually one lobe or a part of a lobe; 
left base most frequently, right apex next . 

9. Rales only early, and during reso- 
lution; frequently no signs in opposite 
lung. 

10. Consolidation earlier; second or 
third day. Consolidation complete; area 
usually sharply defined. 

11. Resolution rapid, usually com- 
plete within a week. 

12. Both are rare. 

13. No sequelae except empyema. 



14. Prognosis good; rarely fatal ex- 
cept from complications — empyema, 
meningitis, pericarditis. 

15. Mortality 4 per cent of all cases. 



In the majority of cases the symptoms are plain and the physical 
signs so typical that it is difficult to overlook pneumonia if any degree 
of care is used in the examination of the patient. The difficulties in diag- 
nosis are due to the great variation in the general symptoms, and to the 
late appearance of the physical signs. The error usually made is to mis- 
take pneumonia for some other disease, rather than to mistake some 
other disease for pneumonia. On account of its frequency in children, 
pneumonia should always be excluded before accepting any other ex- 
planation of a continuously high temperature. The rule should be fol- 
lowed, in all cases of acute illness, of making a thorough examination of 
the chest dailv until the diagnosis is clear. If. to high temperature, 



534 DISEASES OF THE RESPIRATORY SYSTEM. 

rapid respiration ami marked leucocytosis are added, one should always 
Buspecl pneumonia, do matter what the other symptoms may be. It 
not infrequently happens that the general symptoms are quite charac- 
teristic and yet the physical signs appear late. In such cases pneumonia 
should always be looked for high in the axilla or just beneath the clavi- 
cle, since it is particularly in the cases of apex pneumonia that this 
obscurity is likely to exist. 

In their onset, scarlet fever, tonsillitis, and gastro-enteritis may all 
resemble pneumonia. Scarlet fever is recognised by the sore throat and 
the characteristic eruption on the second day; tonsillitis, by the local 
symptoms. In infancy, pneumonia often begins with vomiting and 
sometimes there is also diarrhoea, which may lead one to mistake the 
disease for gastro-enteritis. The constitutional symptoms of influenza 
often closely resemble those of pneumonia; the diagnosis is frequently 
in doubt for several days until definite physical signs of pneumonia 
make their appearance. From all other general diseases, pneumonia is 
to be differentiated by the physical signs. 

Pneumonia with marked cerebral symptoms sometimes resembles 
cerebro-spinal meningitis. In both we may have the abrupt onset, con- 
vulsions, delirium or stupor, opisthotonus, prostration, and marked leu- 
cocytosis. The only positive means of differential diagnosis are by the 
physical signs in pneumonia, and the findings of lumbar puncture in 
cerebro-spinal meningitis. 

The question sometimes arises in pneumonia with cerebral symptoms, 
whether or not pneumococcus meningitis also exists. If the nervous 
symptoms are present from the beginning, there is probably no menin- 
gitis. If they develop suddenly during the course or toward the close 
of the disease, meningitis should be suspected. The only positive means 
of differentiation is by lumbar puncture. 

Lobar pneumonia is to be differentiated from a pleuritic effusion. 
The most common mistake is to confound empyema with unresolved 
pneumonia. In pneumonia rarely if ever do the signs point to involve- 
ment of an entire lung. There is increased vocal fremitus, dulness, 
bronchial voice and breathing, and occasional rales or friction sounds. 
In empyema the whole lung is often affected, there is displacement of 
the heart, flatness on percussion, diminished or absent vocal fremitus, 
and although bronchial voice and breathing are present, they are usually 
distant and feeble. There are no rales or friction sounds. In doubtful 
cases an exploratory puncture should always be made. Serous effusions 
give the same physical signs as empyema. 

Prognosis. — There is probably no disease in which the patient ap- 
pears so ill, and yet so often recovers completely, as in lobar pneumonia 
in a child over three years old. Of 1,295 collected cases, chiefly from 
hospital practice, there were but 39 deaths, a mortality of three per cent. 



LOBAR PNEUMONIA. ;,:;;, 

In 187 cases of ray own there were 21 deaths, a mortality of eleven per 
cent. Only one of the fata] cases was o.ver two years old. The differ- 
ence between the mortality among my cases and the genera] mortality 
given, is due to the fact that a Large proportion of the first group v 
observed in children under two years, while of the collected cases, the 
vast majority were in older children. Combining the above figures, we 
have a total of 1,482 cases with GO deaths, a mortality of four per cent. 
In nearly all my eases death was due either to complications or to very 
extensive disease, as when both lungs were involved, or nearly the whole 
of one lung. In only one case was an uncomplicated pneumonia of a 
single lobe fatal. 

The prognosis depends upon the age of the patient, the intensity of 
the infection, as shown by the temperature, the nervous symptoms and 
the pulse, the presence or absence of complications, and the extent of the 
local disease. These factors are to be taken into consideration rather 
than any special symptoms. Early eonvulsions do not materially affect 
the prognosis. Late convulsions are always very unfavourable. 

The occurrence of vomiting, diarrhoea, or marked tympanites late in 
the disease is always unfavourable. 

A temperature range between 102° and 105° F. is the rule, and 
within these limits the fever does not affect the prognosis. Even very 
high temperature does not increase the danger from the disease as much 
as might be expected. Of fifteen cases in which the temperature reached 
106° F. or over, all but three recovered; while of six cases in which it 
was 10G.5 or over, only one died. The highest recorded temperature in 
my cases — 107.5° F. — was in a patient who recovered. A transient rise, 
even though the temperature may go very high, is seldom serious. 
Much more serious is a fever which remains steadily above 105° F., as 
in most cases this accompanies either very extensive disease or pleuro- 
pneumonia. The continuance of the fever after the tenth day is a bad 
symptom; for, although the crisis may be postponed until the twelfth 
day and occur normally, such a prolonged temperature is an indication 
of a new focus of disease or the development of complications. In a 
severe attack, the extension of the disease to another lobe after the fifth 
day is unfavourable. If resolution does not begin soon after the tem- 
perature becomes normal, the development of empyema, or some other 
pulmonary complication, should be apprehended. 

Treatment. — In the treatment of lobar pneumonia in children, sev- 
eral cardinal facts are to be kept in mind. It is a self-limited disease, 
having a strong tendency to recovery in the great majority of eases re- 
gardless of the treatment adopted. The fatal cases are almost always in 
children under two years of age; the rare deaths in older ones are usu- 
ally due to complications. There is no means of treatment by which 
pneumonia can be aborted or its course shortened. It follows, therefore, 



536 DISEASES OF THE RESPIRATOR? SYSTEM. 

that the indications are, so far as possible, to make the patient comfort- 
able during his illness, to watch for complications, and to treat the in- 
dividual symptoms as they arise. 

In the majority of cases, hygienic treatment is all that is required. 
The patient should be kept in bed, no matter how mild the attack; he 
should be disturbed as little as possible. Most children with pneumonia 
get too much treatment. There seems to be a decided advantage not 
only in fresh air, but in cold air. Patients in cold rooms sleep better, 
and cough less, and altogether seem more comfortable than when care- 
fully housed to prevent their " taking cold." Wide-open windows are 
desirable even though the room temperature is constantly as low as 50° 
F. The patient should be properly protected by blankets, flannel wrap- 
pers, woolen stockings, and at times a hot-water bag at his feet. Food 
should be given at regular intervals, not oftener than every three hours. 
It should not be forced when the patient is suffering only from thirst, 
especially early in the attack, when the appetite is often completely lost. 
Water should be allowed freely at all times. 

These measures, careful nursing, an occasional dose of codeine (gr. 
3V to a child of three years) when the patient is very restless, fretful, or 
sleepless, an ice-cap to the head, and cold sponging when the tempera- 
ture makes him uncomfortable, are usually all that is necessary, except 
to keep a sharp lookout for complications. 

Special symptoms may require treatment. When not severe, the 
nervous symptoms may be controlled by codeine alone or in combination 
with small doses of phenacetine or the bromides. Sometimes sponging 
with tepid water is better than drugs. Severe nervous symptoms, such 
as delirium, stupor, great restlessness with impending convulsions, when 
associated with high temperature, call for ice to the head, cold sponging, 
or the cold pack or bath. Pain, if moderate, may be relieved by counter- 
irritation, by a mustard paste, by dry cups, an ice-bag, or by a hot poul- 
tice; if severe, codeine may be used in addition. The cough is rarely 
severe enough to require treatment. When it is so severe as to prevent 
sleep, small doses of Dover's powder or codeine should be given. Anti- 
pyretic measures are not necessarily called for even if the temperature 
is very high. Some nervous children are less disturbed by the tempera- 
ture than by the means used to reduce it. Under such conditions the 
temperature should be closely watched, but not necessarily interfered 
with unless other symptoms develop. The nervous symptoms are a bet- 
ter guide than the thermometer to the use of antipyretics. Cold I be- 
lieve to be the safest and most certain antipyretic we possess. It may 
be used as a cold sponge bath, the cold pack or an ice-bag to the chest. 
There is no objection to the bath except the prejudice of the laity. 
While cold is applied to the trunk the extremities should be closely 
watched, and heat applied if necessary. The duration of the pack or 



PLEUROPNEUMONIA. 537 

bath, and the frequency of their use, will depend upon the individual <■. 
In the majority of cases stimulants are not required. They are called 
for when the pulse is weak, compressible, and rapid, when the face is 
pale and the extremities are cold. The same stimulants are to be em- 
ployed, and in the same waysras in broncho-pneumonia. Circulatory and 
respiratory stimulants are usually required in Larger quantity at the 
time of and just after the crisis; they are to be used as in broncho- 
pneumonia. 

PLEURO-PNEUMONIA. 

Under this term are included cases of pneumonia with an excessive 
amount of pleurisy, the two processes uniting to produce a single clinical 
type of disease. 

In nearly all cases of lobar pneumonia there is a certain amount of 
inflammation of the pulmonary pleura, and also in those cases of broncho- 
pneumonia which are accompanied by any marked degree of consolida- 
tion. In both of these conditions the pleurisy is usually co-extensive with 
the consolidation. But in certain cases, in both forms of pneumonia, 
the amount of pleurisy is excessive, and this so modifies the symptoms 
and course of the disease as to require for them a separate consideration. 
In some it appears that the inflammatory process begins almost simul- 
taneously in the lung and in the pleura; while in others the pleurisy 
follows the pneumonia. These cases are, I believe, almost invariably 
due to the pneumococcus, although in some there is a mixed infection. 

In 398 hospital cases of pneumonia there were 27, or 6.8 per cent, 
which could be classed as pleuro-pneumonia, the diagnosis being con- 
firmed either by autopsy or operation. Of 190 fatal cases, 12.5 per cent 
were cases of pleuro-pneumonia. Most of these hospital patients were 
under three years of age, and the disease is, I think, more frequent at 
this period than in older children. 

Lesions. — Of these 27 cases, 17 were classed as broncho-pneumonia 
and 10 as lobar pneumonia. The left lung was more frequently affected 
than the right in the proportion of three to two. In most of the cases 
the pleura covering the entire lung was involved, even though the pneu- 
monia affected but a single lobe, or only a part of a lobe. In nearly half 
the cases both lungs were involved, but one to a very much less extent 
than the other. In a small number of cases the pleurisy was limited to 
the posterior surface of the lung. 

In pleuro-pneumonia both the visceral and the parietal pleura are 
coated with a layer of yellowish-green fibrin, in thick, shaggy ma- 
causing adhesions of the lung to the chest wall, the diaphragm, and the 
pericardium (Plate XII). The exudation varies between one-eighth 
and one-half of an inch in thickness. It can often he stripped from the 
lung or scraped from the chest wall by the handful. In its meshes small 



538 DISEASES OF THE RESPIRATORY SYSTEM. 

pocketa may form, which contain only a few drops, or sometimes a 
drachm, of pus. or less frequently serum. This is the condition in which 
the lung is usually found where death has occurred at the height of the 
disease. If the process has lasted longer, larger collections of pus may 
be present. The lung itself shows the usual changes of pneumonia, and 
if there has been any considerable accumulation of fluid, there are in 
addition the evidences of compression. 

With pleuro-pneumonia of the left side, the pericardium is occasion- 
ally involved. This was seen in two of my cases, the lesions closely 
resembling those of the pleura. In two cases there was also meningitis, 
and in one peritonitis, the exudation in all cases having the same char- 
acteristics. 

An inflammation of the intensity described is very often fatal in the 
acute stage, if the patient is a child under tw T o years old. Occasionally 
at this age, and very frequently in older children, we see the later stages 
of the process. The most frequent course is for more and more pus to 
be poured out from the inflamed pleura until the chest is filled, the case 
becoming thus one of empyema. Sometimes the fluid is serous instead 
of purulent, but this is very rare in infancy. Under other circumstances 
the exudation is partly absorbed, but the greater part becomes organised 
so as to form a thick jacket of fibrous tissue which binds the lobe or lung 
to the chest wall, and interferes seriously with its subsequent full ex- 
pansion. Chronic interstitial pneumonia may follow. 

Symptoms. — There is little which distinguishes a case of pleuro-pneu- 
monia except the severity of all the constitutional symptoms; the tem- 
perature is often higher, the prostration greater, and the patient in every 
way impresses one as being more seriously ill than with ordinary pneu- 
monia. Sometimes the thoracic pain is more severe and more constant 
than is usual in pneumonia. The diagnosis, however, is to be made by 
the physical signs. 

In the early stage the pleuritic friction sounds are unusually promi- 
nent; after two or three days the signs of consolidation come out clearly 
in most cases, but still accompanied by loud friction sounds. After the 
fibrinous exudation is very abundant, the signs are often obscure and 
confusing, and there may be at no time well-defined signs of consolida- 
tion. There is usually a mingling of the signs of consolidation with those 
of effusion. There is marked dulness, and sometimes flatness. The 
vocal fremitus is apt to be diminished, and it may be absent. Bronchial 
voice and breathing are heard, but they are not distinct as in consolida- 
tion ; they are, however, feeble and distant, as over fluid. There are 
usually coarse, moist, crackling pleuritic sounds, but these may be absent. 
The signs may be found over one entire lung, or they may be limited to 
the posterior region, and even to a single lobe. They resemble those 
present over fluid, with one exception — viz., the heart is not displaced. 



PLATE XII. 




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HYPOSTATIC PNEUMONIA. 539 

If an exploratory puncture is made, nothing is found ; occasionally the 
exploring needle happens to strike one of the small pockets of pus in 
the meshes of the fibrin, and a few drops of pus are withdrawn. If an 
incision is made under the supposition that the case is one of empyema, 
no more pus may be found, the surgeon coming upon the pulmonary 
adhesions as soon as the chest is opened. There is scarcely any condi- 
tion in the chest giving signs more puzzling than those just enumerated. 
They are, however, easily explained by the pathological conditions 
present. 

Prognosis. — The prognosis in pleuro-pneumonia is much worse than 
in simple pneumonia. In infants the outlook is very bad, the majority 
of cases dying during the acute stage. Very young children may be 
overwhelmed with the extent and the intensity of the inflammation, and 
die in four or five days. In children over two years old the most frequent 
result is for the case to go on to empyema, which with proper treat- 
ment usually terminates in recovery. Where there is organisation of the 
fibrin with the production of extensive adhesions, the ultimate result is 
often not so favourable as when empyema develops. Convalescence is 
usually slow, and the patients are liable to exacerbations of pleurisy; 
they may suffer for years from the partial crippling of one lung. 

Treatment. — Cases of pleuro-pneumonia are to be managed like the 
ordinary cases of pneumonia of the severe type. In some, the excessive 
pain may call for more active counter-irritation and a freer use of opium 
than in other forms of pneumonia, and the greater prostration may re- 
quire that stimulants be given earlier and in larger quantities. 



HYPOSTATIC PNEUMONIA. 

This can not often be recognised clinically, but it is very frequently 
seen upon the post-mortem table. It represents an inflammatory process 
of a low grade and is seen to some degree in almost every case where an 
infant has died of chronic disease. It is particularly frequent in those 
who have died of marasmus. It invariably occupies a strip along the 
posterior border of both lungs, and usually of both the upper and 
lower lobes. This is from one to two inches wide, of a uniform dark- 
red colour, and is sharply outlined. The pleura is not involved, and 
the remainder of the lung may be normal, congested, or slightly 
emphysematous. On section, it is seen that the pneumonic area is 
quite superficial, rarely involving the lung to a greater depth than 
half an inch. Under the microscope there is found a distention of the 
small blood-vessels in the affected area, and the air vesicles are filled 
with many red blood cells, epithelial cells, and a few leucocytes. Be- 
tween the areas of consolidation are groups of air vesicles which are 
normal, congested, or collapsed. It is a lobular rather than a broncho- 



54Q DISEASES OF THE RESPIRATORY SYSTEM. 

pneumonia. The Lesions in this form of pneumonia are probably the 
result of venoua stasis, owing to the child's recumbent position. 

At autopsy the condition may be confounded with atelectasis. Lit- 
gnificance is to be attached to the finding of hypostatic pneumonia 
at autopsy, and it alone should never be regarded as a sufficient cause of 
death, although it is perhaps the only lesion present. During life it 
may give rise to tine moist rales, which are heard along the spine, 
usually upon both Bides; hut there is neither dulness nor bronchial 
breathing. 

The treatment is that of the primary disease. 

CHRONIC BRONCHOPNEUMONIA— CHRONIC INTERSTITIAL 
PNEUMONIA— BRONCHIECTASIS. 

Chronic broncho-pneumonia is an inflammation of the connective- 
tissue framework of the lung, involving the stroma, the alveolar septa, 
the walls of the bronchi, and the pleura. It is usually accompanied by 
cylindrical dilatation of the bronchi — bronchiectasis. 

Etiology. — In children, as in adults, this process is most frequently 
associated with pulmonary tuberculosis ; but in early life it is not an in- 
frequent condition apart from tuberculosis. The non-tuberculous cases, 
as a rule, are preceded by an attack of acute broncho-pneumonia, some- 
times by several such attacks, separated by longer or shorter intervals. 

Lesions. — The part of the lung affected may be an entire lobe, but 
usually it is a portion of one lobe, or there are areas in more than one 
lobe. There are dense connective-tissue adhesions binding the diseased 
part to the chest wall, to the diaphragm and to the pericardium, often 
so firmly that the lung is torn on removal. The affected lung is smaller 
than in health; it is hard, tough, and fibrous. Surrounding the fibrous 
portions are emphysematous areas. On section, the process is seen to 
be somewhat irregularly distributed through the lung, the lesion being 
usually most marked in the vicinity of the smaller bronchi, and some- 
times seen only there, the intervening lung being nearly normal (Plate 
XIII). In some portions, where the process is most advanced, almost 
all trace of lung tissue may have disappeared, the part resembling a solid 
fibrous tumour, through which run the bronchial tubes, usually much 
dilated. In places this dilatation may be sufficient to form cavities of 
considerable size. The bronchial glands are often enlarged to the size 
of a hazelnut, and they may be tuberculous. 

Upon examination with the microscope, the pleura is found greatly 
thickened, with bands of new fibrous tissue passing from it into the lung. 
The walls of the small bronchi are in most places thicker than normal, 
but elsewhere they have undergone cylindrical dilatation, and are filled 
with pus. The walls of the alveoli show a marked proliferation of the 



PLATE XIII. 




Chronic Broncho-Pneumonia. 

In the greater part of the specimen the disease is limited to the vicinity of the 
small bronchi, A A A, each of which is surrounded by a zone of new connective 
tissue, the result of the inflammatory process, the intervening lung tissue, B B, being 
normal. In the lower left-hand portion, the disease is more diffuse ; the air vesicles, 
C, between the areas of new connective tissue are greatly compressed, and in some 
places entirely obliterated. (After Delafield.) 



CHRONIC BRONCHO-PNEUMONIA. 541 

connective-tissue elements, and the alveoli are filled with organised in- 
flammatory products, so that they are nearly or quite obliterated. The 
stroma is much increased in amount throughout the affected lung. 

Symptoms. — In most of the cases there is a history of an attack of 
acute broncho-pneumonia, from which the child made a slow convales- 
cence, remaining pale, anaemic, and sometimes wasted for several months. 
Improvement then took place in the general symptoms, the appetite and 
strength returned, and in many cases the lost weight was nearly or quite 
regained. However, neither the pulmonary symptoms nor the physical 
signs entirely disappeared. There remained a dry, hard cough, which at 
times was severe. Pains in the chest were occasionally complained of, 
and perhaps shortness of breath on exertion was noticed. 

Examination shows a persistence of the dulness on percussion, with 
a rude or broncho-vesicular respiratory murmur of very feeble intensity. 
Little change may take place in these signs for months; then an acute 
attack of bronchitis or broncho-pneumonia may occur. If the latter, the 
same lung is affected, and a fresh consolidation is added to the previous 
disease. This attack may not be very severe, but it drags on for several 
weeks, with slight fever and little or no change in the physical signs. 
Partial resolution may then take place, but the lung is left much more 
seriously crippled than before. Often there is a history of several such 
attacks, each one leaving the lung a little worse than it found it. 

The characteristic physical signs of chronic broncho-pneumonia are 
not usually present until the process has continued for many months. 
They may be found over part of a lobe, or over an entire lobe, or even the 
greater part of one lung. On inspection, there may be seen, in a well- 
marked case, retraction of the chest, which is especially noticeable when 
the disease is situated at the apex of the lung. The vocal fremitus is 
usually increased, but it may not be abnormal. There is marked dulness, 
often flatness, over the affected area, with exaggerated resonance over 
the rest of the lung. The area of flatness shades off gradually. The most 
striking thing on auscultation is the very feeble respiratory murmur; in 
many cases the lung is almost silent. More rarely there is marked bron- 
chial voice and breathing. Rales and friction sounds are usually absent 
except during an acute exacerbation of the symptoms, when they may 
be heard as in any attack of broncho-pneumonia. In recent cases there 
is no displacement of the heart; in those of long standing it may be 
drawn far to the affected side by contraction of the adhesions. 

When the lesions are once present complete recovery is impossible, 
and there is always a tendency for them to increase rapidly or slowly, 
according to the child's vigour of constitution, its surroundings, and the 
frequency with which exacerbations occur. If the disease is extensive 
the patient often succumbs to some intercurrent disease or to an acute 
attack of pneumonia ; if limited in area, the process may be arrested and 



542 DISEASES OF THE RESPIRATORY SYSTEM. 

the patient recover, always, however, to be more or less embarrassed 
because of the crippling of a part of one lung. Not a small number of 
these children ultimately die of tuberculosis, and in such cases it is al- 
ways a difficult matter to decide whether tuberculosis was present from 
the beginning, or whether it was due to subsequent infection. 

The eases in which bronchiectasis is the most important condition 
are not common. The onlv characteristic additional symptom is a 
copious muco-purulent expectoration, which is usually very foetid. It 
may amount to several ounces a day, and is expelled after paroxysms of 
coughing, which usually occur in the morning. This may continue for 
months, or even years, and yet these patients are generally without fever, 
seldom lose weight, and may have the appearance of being in very good 
health. It is rare that the physical signs of a cavity are present. 

Prognosis. — This depends on the extent of the disease, the patient's 
age and constitution, and on our ability to prevent by treatment, climatic 
and otherwise, the occurrence of acute exacerbations. Under the most 
favourable conditions, a few patients may recover completely so far as 
symptoms are concerned; but the majority remain at best delicate dur- 
ing childhood, or even throughout life. 

Diagnosis. — The most important thing is to distinguish between the 
simple and the tuberculous cases, and this, by symptoms and physical 
signs, is in the majority impossible. If the family history is good, if 
the patient lives in the country, if his symptoms begin with a well-de- 
fined acute attack of pneumonia, if the seat of disease is the base pos- 
teriorly, and if the examination of the sputum is negative, the process 
is probably simple. If the family history is doubtful or is positively 
tuberculous, if the patient lives in the city, and especially if he is an 
inmate of an institution or if his home is among the tenements, if the 
initial symptoms are indefinite, if the disease is situated anteriorly, the 
process is probably tuberculous. The cutaneous tuberculin test aids 
much in diagnosis. With a negative reaction tuberculosis can be ex- 
cluded almost with certainty ; but a positive reaction does not prove that 
the pulmonary process is tuberculous, although it is strongly suggestive. 
The discovery of tubercle bacilli in the sputum is, of course, conclusive. 

Foreign bodies in the lung may give symptoms of chronic broncho- 
pneumonia; metallic and most solid substances may be detected by the 
X-ray. 

Treatment. — Xothing has any essential influence upon the disease 
except change of climate. This should be the same as for tuberculous 
cases. The treatment of the patient has for its object the maintenance 
of the general nutrition at its highest point, by careful feeding, judicious 
exercise, and by most of the measures enumerated in the chapter on Mal- 
nutrition. Cod-liver oil should be given throughout every winter season. 
The cough may be treated as in cases of chronic bronchitis. 



ABSCESS OF THE LUNG. 543 

Cases of bronchiectasis may obtain considerable relief from inhala- 
tions of creosote. They should not be operated upon. 

ABSCESS OF THE LUNG. 

Multiple small abscesses are not uncommon as a termination of acute 
broncho-pneumonia, in which connection they have already been consid- 
ered. Larger non-tuberculous abscesses of the lung are rare, very obscure 
in their symptoms, and apt to be mistaken for localised empyema, some- 
times for interstitial pneumonia with bronchiectasis. Three such cases 
have come under my observation. 1 One was discovered at autopsy, the 
other two were recognised during life and successfully treated by opera- 
tion. Other examples in young children have been reported by Huber 
and by Hedges. The cause of these single abscesses is usually a previous 
attack of acute primary pneumonia, less frequently an inflammation ex- 
cited by a foreign body in the lung. 

An abscess due to a foreign body is usually accompanied by wasting, 
and a widely fluctuating temperature of a hectic type — symptoms sug- 
gestive of a rapidly advancing tuberculous process. If the abscess fol- 
lows an ordinary pneumonia the course is generally less intense. The 
constitutional symptoms differ little from those of empyema. There is 
an irregular type of fever, sometimes quite high, but more often only 
from 99° to 101° or 102° F., a moderate cough, not much wasting, and 
generally not very marked prostration. A leucocytosis of 30,000 to 50,- 
000 is usually present. The physical signs are somewhat confusing and 
are a combination of those present in effusion and consolidation. There 
is an area of flatness shading off into dulness. The vocal fremitus may 
be increased or it may be diminished. The respiratory murmur is very 
feeble or absent over the abscess, often it is broncho-vesicular in charac- 
ter. Friction sounds and rales are usually present. The heart is slightly 
or not at all displaced. If an exploratory needle is introduced, pus may 
not be found even by repeated punctures; or it may be obtained at one 
time and not at another, although introduced in the same intercostal 
space, the difference in result being due to the direction in which the 
needle is passed into the lung. When pus is found, the diagnosis of a 
localised empyema is generally regarded as established, and it is not 
until the chest is opened that the mistake is discovered. The operator 
then comes upon the lung, which may or may not "be adherent. If the 
abscess follows an acute pneumonia the pus may show a pure culture of 
the pneumococcus. If it is due to a foreign body, there is invariably 
a mixed infection, and the pus is apt to be foetid. 

When not treated surgically, abscess of the lung may rupture into 
the pleural cavity, producing a secondary empyema, or spontaneous 

1 Archives of Paediatrics, January, 1904. 



544 DISEASES OF THE RESPIRATORY SYSTEM. 

evacuation mav take place through a bronchus and recovery follow. 
When the cause is a foreign body rapid recovery often follows its expul- 
sion by coughing. If the diagnosis is made and proper surgical treat- 
ment is instituted, recovery occurs in probably the majority of oases. 

The genera] plan of treatment should be the same as in empyema. 
In a small proportion o\' rases aspiration may suffice for a cure. How- 
ever, incision is usually necessary. If the pleura is not adherent, adhe- 
sions should be excited by packing the thoracic wound with gauze, and 
after a few days a Becond operation may be done. The lung should be 
opened with a blunt instrument, following the line of the exploring 
needle, and a drainage-tube inserted as in empyema, the subsequent treat- 
ment being the same as for that disease. 

GAXGREXE OF THE LUNG. 

Pulmonary gangrene is rare in children, although probably more com- 
mon than in adults. It is most frequently associated with pneumonia. 
It is usually circumscribed, and seldom diagnosticated during life. 

Etiology. — All my cases have been in children under three years old, 
the youngest an infant of four months. Gangrene occurs for the most 
part in children who are ill-conditioned, feeble, or cachectic, and often 
follows one of the infectious diseases, particularly measles. Of nine 
cases which have come under my personal observation, six complicated 
aeute broncho-pneumonia and one lobar pneumonia. Pulmonary gan- 
grene has been present in three per cent of my autopsies upon cases of 
pneumonia. The immediate cause of the necrotic process is interference 
with the circulation in a part of the lung, which is usually due to throm- 
- - or embolism of some of the branches of the pulmonary artery. To 
this there is added the entrance of putrefactive bacteria. In some cases 
pulmonary gangrene may begin as a septic thrombosis, this infection 
originating in some process in a distant part of the body. 

Lesions. — The lower lobes are more frequently affected than the up- 
per, and the surface of the lung rather than the central portions. 

Two form- of gangrene may be seen: the diffuse form, which affects 
a whole lobe, or even a whole lung; and the circumscribed form, which 
occurs in a number of small scattered areas. The latter is the variety 
usually seen in children. In the diffuse form the lung is of a dirty 
green or brown colour, moist, and emits a gangrenous odour. In the 
circumscribed form, when occurring in pneumonia, the parts affected 
are of a gray or green colour, usually wedge-shaped, with the base at the 
surface of the lung. In the early stage they are not softened, and have 
no gangrenous odour; later, both these conditions may be present, and 
- of necrotic lung tissue may be found in a cavity with ragged walls, 
partly filled with foetid pus. Careful dissection will reveal, in many 



ACQUIRED ATELECTASIS— PULMONARY COLLAPSE. 545 

cases, the presence of thrombi in the vessels leading to the gangrenous 
parts. 

Symptoms. — There are but two distinctive symptoms of pulmonary 
gangrene : the gangrenous odour of the breath, and the expectoration of 
masses of necrotic lung tissue. In the cases associated with acute pneu- 
monia, which include the majority of those seen, death nearly always 
takes place before there is any separation of the sloughs, and even before 
very active decomposition in the necrotic areas has occurred. Both the 
peculiar symptoms are therefore wanting, and the diagnosis is made 
only at the autopsy. This has been true of nearly all the cases which 
have come under my own observation. But these patients, with one ex- 
ception, were infants. In older children, particularly in cases secondary 
to the entrance of- a foreign body, the characteristic symptoms are more 
frequently seen, and there may be a third symptom — haemorrhage. This 
is present in about one-fourth of the cases (Rilliet and Barthez), and 
may be fatal. The general symptoms associated with gangrene are those 
of profound asthenia, resembling the typhoid condition. 

From what has been said, it will be evident that the diagnosis is very 
difficult. If the characteristic odour of the breath is present, conditions 
in the mouth from which it might arise must be excluded. The physical 
signs differ in no respect from those of ordinary cases of pneumonia. 
The termination is almost always in death. This is due not only to the 
condition itself, but to the circumstances in which it is seen. 

Treatment. — The general treatment should be supporting and stimu- 
lating, as in all severe cases of pneumonia. For the local process but 
little can be done, except the inhalation of antiseptics, of which creosote 
and turpentine are undoubtedly the best. 

ACQUIRED ATELECTASIS— PULMONARY COLLAPSE. 

These terms are. applied to a state of the lung resembling the foetal 
condition, but occurring in a lung which has once been expanded. It 
may be due to compression or to obstruction. 

Collapse from Compression. — The principal cause of this form is pleu- 
ritic effusion. It may also be produced by pneumothorax, enlargement 
of the heart, pericardial effusion, deformities of the chest from rickets 
or Pott's disease, and tumours of the mediastinum or the thoracic wall. 
In these conditions, on account of the external pressure, the air vesicles 
are not filled, although the bronchi are pervious. After collapse has 
existed for a considerable time, changes may take place in the lung 
which render expansion difficult or impossible. Unless, however, there 
are pleuritic adhesions, expansion often takes place readily after many 
weeks and even months. The symptoms and signs are those of the orig- 
inal disease. 
36 



546 DISEASES OV THE RESPIRATORY SYSTEM. 

Treatment is available chiefly in that form which follows pleuritic 
effusion, and will be considered in the chapter on Empyema. 

Collapse from Obstruction. — This is due to two factors: blocking of 
either the large or small bronchial tubes, and feeble inspiratory force. 
The importance of collapse from obstruction in the acute diseases of 
the lung in infancy has, I think, been exaggerated. Whenever a large 
or small bronchus is completely obstructed by a foreign body, the portion 
of the lung to which the bronchus is distributed gradually becomes col- 
lapsed. If it is one of the primary bronchi which is occluded, a whole 
lung may be collapsed; if one of the lobar divisions, an entire lobe; if 
one of the smaller divisions, only a small area. The collapse does not 
take place immediately, but the contents of the air vesicles are gradually 
absorbed by the blood. The collapsed portion is slightly depressed below 
the surface of the lung. It is of a dark-red colour, very vascular, and 
to the naked eye resembles a pneumonic area, which it may subsequently 
become. 

Many writers explain the development of broncho-pneumonia from 
bronchitis of the smaller tubes, through the intervention of pulmonary 
collapse, assuming that the obstruction of the small bronchi, from swelling 
of their walls and the accumulation of secretion, produces the same re- 
sult as the plugging of a bronchus by a foreign body. In my own autop- 
sies I have found little support for this theory. In acute bronchitis of 
the smaller tubes the lumen is narrowed, but seldom enough to prevent 
the entrance of air. The result is usually emphysema, not atelectasis. 
Such, at least, has been the condition I have most frequently found in 
autopsies in the earliest stage of broncho-pneumonia following bronchitis 
of the fine tubes. There are very often groups of collapsed air vesicles 
surrounding pneumonic areas, but these are neither an essential nor a 
very important part of the lesion. Collapse of a large part of the lung, 
or even of a lobe, I have never seen, either in pertussis or in acute 
bronchitis. 

There is seen in delicate or rachitic infants a form of collapse which 
comes on very gradually. It is accompanied by bronchitis affecting the 
tubes in the dependent part of the lung. It may resemble the congenital 
form of atelectasis. Under the microscope there is almost invariably 
found, accompanying the collapse, lobular pneumonia and bronchitis of 
the tubes in the affected regions. 

The symptoms of acquired atelectasis are much the same as in the 
persistent congenital form. The respiration is rapid, and there may be 
inspiratory dyspnoea with deep recession of the chest walls, especially if 
there is rickets. There is also cyanosis of variable intensity. The tem- 
perature is not elevated, but frequently is subnormal. The physical signs 
are very uncertain. There is usually feeble respiratory murmur over the 
affected areas, occasionally accompanied by moist rales. The essential 



EMPHYSEMA. 547 

point of difference between these eases and those of congenital atelectasis 
is that in the former the patients are often strong at birth, crying and 
breathing well, giving no signs of anything wrong in the lungs until the 
general nutrition has suffered from some other cause. 

The following is a fairly typical case: A female infant thirteen 
months old had been under observation for several months before death. 
During this period she suffered a great part of the time from mild bron- 
chitis. The chest was extremely rachitic. The respiration was always 
accelerated, and on inspiration the lateral recession of the chest was at 
times extreme. There was occasionally seen slight cyanosis, and during 
the last few weeks it was constant. Death occurred quite suddenly. At 
autopsy there was found very marked vesicular emphysema of both lungs 
in front. Nearly the whole of both lower lobes were in a condition of 
collapse, and of a uniform grayish-purple colour. The posterior portion 
of the upper lobes was similarly affected, but to a less degree. With 
moderate force all of the collapsed areas could be completely inflated. 
Bronchitis was present, but the pleura was normal. 

The treatment of these cases is the same as that outlined in the 
chapter upon Congenital Atelectasis. 

EMPHYSEMA. 

Pulmonary emphysema consists primarily in overdistention of the air 
vesicles. It may result in their rupture and the escape of air into the 
interlobular connective tissue of the lung. In infancy and childhood 
emphysema is usually associated with acute processes. 

Etiology. — Cases of emphysema are divided into two groups which are 
due to quite different causes. In one group it is compensatory, and con- 
sists in overdistention of the air vesicles in certain parts of the lungs 
because the full expansion of other parts is prevented either because they 
are consolidated, as in pneumonia or tuberculosis, bound down by ad- 
hesions from old pleurisy, or subjected to external pressure, as from chest 
deformities due to Pott's disease or rickets. In these conditions it is 
probable that the emphysema is produced during inspiration. It may 
also be produced by the artificial inflation of the lungs of the newly born. 

In the second group of cases emphysema is produced by obstructive 
expiratory dyspnoea or cough. It is seen in all forms of laryngeal stenosis, 
in acute bronchitis and broncho-pneumonia, in asthma, pertussis, and 
occasionally it is produced by any condition which requires deep inspira- 
tion andliolding the breath. In bronchitis the obstruction may be caused 
by a swelling of the mucous membrane or by an accumulation of secretion. 
In this group of cases air enters the lung, but as it can not readily escape, 
the air vesicles are distended, sometimes to such a degree that their 
resiliency is almost entirely lost. 



548 DISEASES OF THE RESPIRATORY SYSTEM. 

Lesions. — The most common form in early life is acute vesicular 
emphysema, which occurs when the force distending the air cells is only 
moderate. In this form there is dilatation of the vesicles with very 
slight structural changes, there being usually rupture of a few alveolar 
septa only (Fig. 73). Although the dilatation may be quite marked, 
the emphysema is not permanent. The parts most affected are the upper 
lobes, particularly the anterior borders. In appearance the emphysema- 
tous lung is pale, sometimes almost white. The areas are prominent, and 
do not collapse upon opening the chest. With a lens, or even with the 
naked eye, the individual air vesicles can often be distinguished as minute 
pearly bodies, at times resembling miliary tubercles. When the disease 
is secondary to acute bronchitis or laryngeal stenosis it may affect nearly 
the whole of both lungs. 

With a greater distending force rupture of many of the air vesicles 
results, and this may give rise to interstitial or interlobular emphysema. 
At times blebs are formed, varying in size from a pin's head to a cherry 
or even larger. These are usually seen at the anterior border or at the 
root of the lung on its inner surface. Again, the air finds its way between 
the lobules, dissecting them apart in all directions throughout the lung. 
Sometimes a large part of the surface of both lungs is seamed with ir- 
regular deep crevasses containing air, the largest being an inch or more 
in length and nearly one-fourth of an inch wide. The most severe cases 
occur in pertussis. On two or three occasions I have seen this form of 
emphysema, once to an extreme degree, where children had died from 
diseases unconnected w T ith the respiratory tract, and where no history 
could be obtained which threw any light upon the etiology of the em- 
physema. Eupture of the blebs which form at the root of the lung may 
lead to emphysema of the mediastinum, or even of the subcutaneous con- 
nective tissue of the body. This is occasionally seen in whooping-cough 
and in laryngeal stenosis. The primary or substantive form of em- 
physema seen in adult life rarely if ever occurs in childhood. 

Symptoms. — Emphysema occurring in acute pulmonary diseases gives 
rise to no peculiar symptoms and to no physical signs except exaggerated 
resonance upon percussion. This masks dulness from consolidation and 
also that from the liver and spleen. If the patients recover from the 
original disease, the emphysema greatly diminishes or disappears com- 
pletely in the course of a few weeks or months. Acute interlobular 
emphysema can not be diagnosticated during life, unless, as is sometimes 
the case, general subcutaneous emphysema is seen, which may come on 
quickly, last for several hours or days and then gradually disappear. 

The treatment of emphysema is that of the disease with which it is 
associated. 



DRY PLEURISY. 549 

CHAPTER VI. 
PLEURISY. 

All the common forms of inflammation of the pleura are seen in 
childhood. In the great majority of cases they are secondary to disease 
of the lung itself. Serous effusions are much less frequent than in adults, 
and under three }^ears they are rare. Purulent effusion (empyema) is, 
however, much more often seen than in adult life, and it is the most 
important variety of pleurisy with which the physician has to deal. 

Whether inflammation of the pleura ever occurs as a strictly primary 
disease is still a mooted point. Cases are occasionally observed clinically 
in which both the serous and purulent forms of the disease appear to be 
primary, but these are extremely rare. Acute pleurisy may, however, 
follow inflammation of the lung so rapidly that it is not easy to de- 
termine that the lung was first affected. In infants, extension from the 
lung is almost the sole cause. It occurs both with lobar and broncho- 
pneumonia, existing to some degree in nearly every case in which there 
is consolidation of the lung. Next in frequency to simple pneumonia as 
a cause of pleurisy are the tuberculous processes of the lung. Tuber- 
culous pleurisy without tuberculosis of the lungs or the bronchial glands 
is of doubtful occurrence. Acute pleurisy is not an infrequent complica- 
tion of the infectious diseases, particularly scarlet and typhoid fevers, 
measles, and influenza. In most of these cases also it is secondary to 
disease of the lung. Pleurisy in older children occasionally follows 
cold and exposure, although it is doubtful whether in any case this 
is the only cause. In them also it may occur as a complication of rheu- 
matism. 

The most important cause of acute pleurisy being extension from 
pneumonia, it follows that it is most frequent in the cold season, that it 
occurs more often in males than in females, and between the ages of one 
and five years. It may, however, be seen at all ages, and may even occur 
in intra-uterine life. The youngest case in which I have found ex- 
tensive pleuritic adhesions as an evidence of previous inflammation was 
in an infant of three months. In this case firm connective tissue ad- 
hesions were found over the whole of both lungs. 

DRY PLEURISY. 

In infants and young children this usually accompanies pneumonia or 
tuberculous processes in the lung. In older children it may be primary. 

Lesions. — On account of the frequency with which this occurs in 
pneumonia we have an opportunity of observing it in all stages. In the 
mildest varieties it affects only the pulmonary pleura, and occurs over the 



550 DISEASES OF THE RESPIRATORY SYSTEM. 

pneumonic areas. The pleura is injected, lias lost its lustre, and appears 
dull or roughened. This is due to an exudation of fibrin upon its sur- 
face. It* the process continues, more fibrin is poured out, and there are 
in addition swelling and a proliferation of the connective-tissue cells, and 
an exudation o\' Leucocytes from the blood-vessels. The pleura is then 
coated with a layer o( fibrin of variable thickness, in which are entangled 
pus rolls and new connective-tissue cells. The layer of fibrin varies from 
the thickness of tissue paper to that of an ordinary book cover. In re- 
cent cases it may easily be stripped off, while in older ones it becomes 
organised and is firmly adherent. The colour of the exudate varies with 
the number of pus cells. It is gray, grayish-yellow, or yellowish-green, 
according as these colls are few or numerous. As a rule, dry pleurisy 
is localised, but the two opposing surfaces are affected. Part of the 
exudate is usually absorbed, but it is doubtful if complete recovery oc- 
curs, there being left behind some adhesions between the visceral and 
parietal layers. 

In the dry form of tuberculous pleurisy there may be only an ex- 
udation of fibrin, or the pleura may be covered with gray tubercles and 
yellow tuberculous nodules. These are not only seen upon the pleura, 
but develop in the exudation. In this form, which is usually chronic, 
great thickening of the pleura may take place. Both the serous and 
purulent effusions occurring in conjunction with tuberculosis are likely 
to be sacculated because of the previous existence of adhesions. 

After nearly every case of dry pleurisy there probably remains some 
slight thickening of the pleura. In certain cases there follows a chronic 
inflammation of the pleura with the production of new connective tissue, 
which results in thickening and adhesions, which may be so extensive as 
to entirely obliterate the pleural cavity. Either one or both sides may 
be affected. It is usually accompanied by external pericarditis. This 
form is extremely rare in childhood. 

Symptoms. — As an independent clinical disease, acute dry pleurisy 
has no existence in infancy or early childhood. The cases which are occa- 
sionally so diagnosticated have in my experience invariably proven to be 
broncho-pneumonia. In children from ten to fourteen years old, dry 
pleurisy may occur under the same conditions as in adults. 

The symptoms are sharp, localised pain, increased by full inspiration, 
sometimes tenderness upon pressure, and a short, teasing cough. The 
pain is not always felt upon the affected side, and it may be referred to 
the abdomen. Upon physical examination, dry pleurisy is recognised 
by the presence of a pleuritic friction sound. This is usually of a moist, 
crackling character, generally localised, and heard both on inspiration 
and expiration. It is quite superficial, and not changed by coughing. 
This form of pleurisy, as a rule, runs a course of a few days ot a week, 
without constitutional symptoms. When dry pleurisy occurs as a com- 



PLEURISY WITH SEROUS EFFUSION. 55] 

plication of pneumonia it is recognised by the Bigns just mentioned; but 

it usually causes no new symptoms except pain. 

Treatment. — The treatment consists in counter-irritation by mustard, 
iodine, or blisters, according to the severity of the inflammation, and in 
the use of opium. Severe pain can sometimes be relieved by firmly en- 
circling the chest with a broad band of adhesive plaster. 



PLEURISY WITH SEROUS EFFUSION. 

This form of pleurisy is not common in young children, and in in- 
fants it is rare. It usually occurs as a complication of pneumonia, but 
may be seen in nephritis, acute rheumatism, scarlet fever, or any of the 
other acute infectious diseases. It may be tuberculous. In rare cases it 
appears to be primary. Bacteria are occasionally present in the exuda- 
tion, even in cases which do not become purulent, but their number is 
usually small. The pneumococcus, the streptococcus, and the tubercle 
bacillus are the forms most often seen. 

Lesions. — The early changes are much the same as in dry pleurisy, 
but in addition serum is poured out from the blood-vessels, in some cases 
almost from the beginning of the inflammation. This may be small in 
amount, or it may fill the pleural cavity. The lesions are similar to those 
seen in adults, except that in children there is apt to be more fibrin. The 
process usually terminates in absorption of the serum, but, as in dry 
pleurisy, more or less extensive adhesions are left behind from the fibri- 
nous exudation. In other cases there is at first a clear serum, often con- 
taining pneumocoeci, then it becomes somewhat turbid, and finally 
purulent. This is especially common in infants. 

Symptoms. — The small serous effusions of one or two ounces, occur- 
ring with the pleurisy that complicates pneumonia, rarely cause cither 
symptoms or physical signs by which they can be recognised. In the 
present connection only those cases will be discussed in which the amount 
of effusion is considerable. This form of pleurisy sometimes follows a 
well-defined attack of pneumonia. Other cases come on with acute febrile 
symptoms somewhat resembling those of pneumonia, but with all the 
symptoms less severe, except the pain. After an illness of only two or 
three days the chest may be found full of fluid. In a third class the 
disease comes on insidiously, with little or no fever, and often with no 
distinct pulmonary symptoms except shortness of breath. There are gen- 
eral weakness, sometimes loss of flesh, anaemia, and moderate prostration ; 
but usually the patients are not sick enough to go to bed. The symp- 
toms of pleurisy with effusion vary greatly. When it occurs as a com- 
plication of some acute infectious disease, it is often latent, and the 
diagnosis is to be made only by the physical examination of the etc 

In cases in which the fluid does not become purulent, the usual course 



552 DISEASES OF THE RESPIRATORY SYSTEM. 

of the disease is for the fluid to disappear gradually by absorption, the 
ease going on to spontaneous recovery. Serious symptoms resulting 
from pressure upon the heart and lungs are not common, but may occur 
when the fluid accumulates rapidly; hence they are most likely to be 
seen early in the attack. There may be great dyspnoea, sometimes 
orthopiuva. cyanosis, weak pulse, and even attacks of syncope. Death 
may occur with these symptoms. In certain cases there is seen no 
tendency to spontaneous absorption, and the exudation may remain sta- 
tionary for months. There may then be fever, usually slight but some- 
times quite regular, with a decline in the general health, pallor and 
anaemia, which may strongly suggest the existence of pus, although this 
is not present. Others are regarded as cases of tuberculosis. 

Physical Signs. — The signs in the chest are essentially the same 
whether the fluid is serous or purulent. On inspection, there is dimin- 
ished movement of the affected side, sometimes bulging of the intercostal 
spaces, and if the effusion is large, an increase in the measurement of 
the affected side of the chest. The apex beat of the heart will usually 
be considerably displaced if the effusion is upon the left side. It may 
be found at the epigastrium, at the right border of the sternum, or even 
in the right mammary line. In disease of the right side the displacement 
is less, and occurs only with a large effusion. It may then be found in 
or near the left axillary line. On palpation, the vocal fremitus is usually 
diminished or absent, but it may be but little changed. Percussion gives 
marked dulness or flatness. In a large effusion this is over the entire 
lung. There is also a sensation of increased resistance appreciable by the 
percussing finger. With a smaller effusion there is usually flatness over 
the lower part of the chest and dulness or tympanitic resonance above; 
sometimes dulness is found behind and tympanitic resonance at the apex 
in front. The line of flatness may change with the position of the patient. 
Grocco's sign is found in the majority of cases. This is a triangular 
area of dulness posteriorly, with its base to the spine, on the side opposite 
to the effusion. The signs on auscultation are variable, and probably 
lead to more frequent mistakes in diagnosis than in any other pulmonary 
affection. Bronchial breathing and bronchial voice over the fluid are 
common in children. Absence of both voice and breathing is sometimes 
met with, but it is exceptional. The bronchial breathing over fluid usu- 
ally differs from that over consolidation, in that it is feebler and dis- 
tant ; in some cases, however, it is indistinguishable from that heard over 
consolidation. Friction sounds may be heard above the level of the fluid, 
or when the fluid is subsiding, and there may be bronchial rales. 

Diagnosis. — The most reliable signs for diagnosis are displacement 
of the heart, flatness on percussion, absence of rales and friction sounds, 
and (usually distant) bronchial breathing. In an infant, flatness should 
always lead one to suspect fluid. If there is flatness over one entire 



PLEURISY WITH SEROUS EFFUSION. 553 

lung, the existence of fluid is almost certain. Between serous and puru- 
lent effusions a positive diagnosis is possible only by tbe use of the ex- 
ploring needle. This should be employed in every case, as for treat- 
ment it is important to know at once whether or not we have a purulent 
effusion to deal with. The amount of fluid in serous pleurisy is generally 
less than in the purulent variety. 

Pleurisy is further to be differentiated from pneumonia, and from 
tuberculosis. From pneumonia, the acute cases are distinguished by the 
lower temperature, the less severe prostration, and the fact that all 
the general symptoms are milder, but especially by the physical signs. The 
differential diagnosis by the physical signs between effusion and the 
various forms of consolidation is considered under the head of Empyema. 

Prognosis. — In the acute cases complicating pneumonia, a serous 
pleurisy is very apt to become purulent. Other forms of pleurisy with 
effusion, as a rule, terminate in recovery. In cases coming on without 
definite cause there should always exist a suspicion of tuberculosis, and 
hence every patient should be closely watched for the development of 
the other signs of that disease. 

Treatment. — In the great majority of cases, only symptomatic treat- 
ment is required during the acute period. The patient should be kept 
in bed, and pain relieved by opium, counter-irritation, or dry cups. After 
the fever has ceased the patient may be allowed to sit up, but all exer- 
tion should be carefully avoided if the effusion is large. Sudden death 
has occurred when this rule has been violated. The patient should in 
suitable weather be kept in the open air as much as possible. In the 
course of a few weeks the effusion usually subsides under simple tonic 
treatment. Absorption may sometimes be hastened by counter-irritation 
and diuretics; but convalescence is apt to be slow, and it may be several 
months before the health is entirely restored. 

The removal of the fluid by operation is indicated in the acute form 
when it is accumulating so rapidly as to endanger life from the pressure 
upon the heart and lungs; also when there is no tendency to absorption 
after from two to three weeks of constitutional treatment. In such cases 
nothing is to be gained by waiting, and harm may be done to the lung 
by the delay. The usual method is by aspiration. In the acute stage 
enough should be removed to relieve the patient's symptoms, aspiration 
being repeated if necessary in twelve or twenty-four hours. In infants, 
particularly, there is great danger of wounding the lung when aspiration 
is repeated several times. This usually results in the production of 
pneumo-thorax which may mask the re-accumulation of the fluid. In 
the subacute stage the removal of a portion of the fluid may be all that 
is required, spontaneous absorption of the remainder often taking place 
quite promptly. A few cases of serous pleurisy have been incised and 
drained as cases of empyema. 



554 DISEASES OF THE RESPIRATORY SYSTEM. 



EMPYEMA. 

Fully nine-tenths of the cases of empyema in children under five years 
either occur with or follow pneumonia, being usually the sequel of the 
form described as pleuro-pneumonia. In some of these cases, however, 
the pleurisy masks the pneumonia, so that the former appears to be the 
primary disease. Tuberculosis is a rare cause in early childhood, but 
becomes more frequent after the seventh year. Empyema may com- 
plicate scarlet fever, measles, or any of the other acute infectious dis- 
eases. It is met with in pyaemia from all causes. It may occur in the 
newly born as the result of infection through the umbilical wound or 
the skin. It is seen with suppurative inflammations of the joints and 
in osteo-myelitis. It may complicate suppurative processes in the ab- 
domen, such as appendicitis or purulent peritonitis. Among the local 
causes may be mentioned traumatism, necrosis of a rib, and the rupture 
into the pleural cavity of abscesses originating in the mediastinum, in 
the thoracic wall, or below the diaphragm. 

Etiology. — Since empyema is generally secondary to pneumonia, its 
causes are mainly those of that disease. Bacteriologically, the cases may 
be divided into several groups : 

1. Those containing the pneumococcus (micrococcus lanceolatus), 
usually in pure culture. This is the largest group, and includes nearly 
all the cases secondary to pneumonia. 

2. Those containing other pyogenic germs, particularly the strepto- 
coccus and the staphylococcus aureus. These organisms may be found 
alone, or associated with the pneumococcus. This combination is likely 
to be found in cases secondary to the pneumonia which occurs with the 
infectious diseases. The streptococcus and staphylococcus occur in the 
pleurisy of pyaemia, and generally also when the disease is due to the 
rupture of abscesses into the pleural cavity. I have once found the in- 
fluenza bacillus as the sole organism in empyema. 

3. The cases due to tuberculosis. These are rare in children and 
almost unknown in infants. The tubercle bacillus is often difficult to 
demonstrate, and it may be absent. But it is not safe to assume that 
tuberculosis is present because no organisms are found. 

Lesions. — Empyema is an inflammation with the production of 
serum, fibrin, and pus. In most of the cases — and the younger the 
child the more frequent its occurrence — it succeeds pleuro-pneumonia. 
There is first an exudation of fibrin with an excess of pus cells. As the 
process continues, more and more pus is poured out, with serum. At 
first the fluid collects in small pockets formed by the slight adhesions. 
As it accumulates these are broken down, and the pleural cavity may be 
filled with pus. If the original inflammation involved but a portion of 
the pleura the empyema may be sacculated. This is often seen even in 



EMPYEMA. 



555 



infants. Sacculated empyema is usually posterior and over one lower 
lobe, but may be in any part of the chest. In very rare cases there maj 
be several sacs containing pus, separated by septa. This I have never 
seen in empyema following pneumonia. The cases just described are 
those in which, in infants and young children, the pneumococcus is reg- 
ularly found. The amount of fibrin is large, covers both surfaces of the 
pleura, and many large masses float in the fluid. The pus is usually 
thick, creamy, and odourless. In another group of cases the evidences 
of inflammation of the pleura are much less marked, and in some they 
may be slight. There is but little fibrin in the exudate, and adhesions 
are rare. In this form the streptococcus or the staphylococcus are the 
organisms usually found. In these cases the inflammation may be 
purulent from the outset, and the pus is thinner than in the preceding 
variety. Empyema following pneumonia is occasionally preceded by a 
serous effusion which, although almost clear, is usually found to contain 
great numbers of bacteria, 
usually pneumococci. 

Even when the fluid 
is moderate in quantity it 
is not all at the bottom of 
the chest, but is generally 
distributed over a consid- 
erable part of its surface, 
and its depth at the mid- 
dle and upper part of the 
chest may be only half an 
inch, or even less. When 
the accumulation is larg- 
er, the lung does not float 
on the surface of the 
fluid, but the fluid sur- 
rounds the lung, which is 
compressed on all sides 
(Fig. 93). The heart is 
displaced; the diaphragm 
and the abdominal viscera 
are somewhat depressed, 
and there may be bulg- 
ing of the chest on the af- 
fected side. The amount 
of fluid in ordinary cases is from four to twenty ounces, although in neg- 
lected cases it may accumulate until it amounts to four or five pints. 
The effect upon the lung will depend upon the amount of fluid and the 
duration of the compression. When the quantity is small, or when the 




Fig. 93. — Section of a Lung. To illustrate the dis- 
tribution of the fluid in the chest in a moderately- 
large effusion (diagrammatic). 



556 



DISEASES OF THE RESPIRATORY SYSTEM. 



pressure is removed early, the lung in most cases readily expands, air 
being forced into it from the opposite lung, especially during the act of 

coughing. With the exception oi' adhesions, recovery may he complete. 
Although wide in extent, the adhesions are not usually strong enough 
to interfere seriously with the function of the lung. If the pressure is 
groat and has been long continued, the adhesions over the lung may 
become so dense and firm that expansion is difficult, and can at best be 
only partial. In such cases recession of the chest wall occurs. In old 
cases, expansion is still further interfered with by the changes taking 
place in the lung itself, usually a low grade of interstitial pneumonia. 

In cases receiving no treatment, absorption of the pus is possible, but 
is not to be expected. It generally seeks an external outlet; the lung 
may be perforated and the pus evacuated through the bronchi, or external 
rupture may occur, generally in the neighbourhood of the nipple. In 
still other cases the pus may burrow along the spine, or through the 
diaphragm reaching the peritonaeum. 

Emp3'ema is more often of the left than of the right side, the propor- 
tion being about three to two. It is double in about three per cent of all 
cases, but much oftener in infants. The most serious complication in 
young children is pericarditis, usually with empyema of the left side ; in 
older children the most frequent complication is pulmonary tuberculosis. 



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Fig. 94. — Empyema following Pneumonia. Private patient, girl, eight years old; se- 
vere pneumonia terminating by lysis ; development of empyema indicated by second- 
ary temperature; operation on seventeenth day; recovery. 



Symptoms. — When it occurs as a sequel of pneumonia, the s} T mptoms 
of empyema may follow those of the original disease without any inter- 
mission; or after the temperature has been normal or nearly so for sev- 
eral days it may rise again, sometimes quite suddenly, but more often 
gradually. With this accession of fever there are other symptoms point- 
ing to an increase in the thoracic disease. (See Figs. 94 and 95.) 
After scarlet fever or other infectious diseases, the onset of empyema is 
often signalised by cough, rapid breathing, and the other usual symptoms 
of pulmonary disease. In the cases where empyema appears to be 



EMPYEMA. 



557 




Fig. 95. — Empyema following Pneumonia. Hospital pa- 
tient, two years old ; single-lobe pneumonia with crisis on 
ninth day; no resolution, but instead gradual develop- 
ment of signs of empyema closely following the temper- 
ature curve. 



primary, the onset is sudden, with high temperature and general and 
local symptoms resembling those of pneumonia. After such a be- 
ginning, the chest may be found full of pus by the third or fourth 
day. In older children empyema may come on with gradual, and even 
insidious symptoms, there being only slight fever, dyspnoea, and 
cachexia. Marked leu- 
cocytosis, 30,000 to 50,- 
000, is almost invari- 
ably present. The 
proportion of poly- 
morphonuclear cells is 
usually from seventy 
to eighty per cent. 

Whatever may have 
been the mode of on- 
set, when the pus has 
been in the chest for 
some time the symp- 
toms are fairly uni- 
form. During the 
acute stage there are present pallor, anaemia, and prostration. The respi- 
rations are always accelerated, being usually from forty to seventy a 
minute. Cough is present; there is dyspnoea, sometimes marked, but 
more often it is scarcely noticeable. The temperature is exceedingly 
variable; usually it ranges from 101° to 103° F. A typical hectic tem- 
perature with sweating, is in my experience very rare. The pulse is 
rapid but of fair strength. There is loss of flesh, sometimes even emacia- 
tion and anorexia; occasionally there is diarrhoea. The stage of acute 
symptoms may last from two to four weeks. This may be succeeded by 
a subacute stage which may last for months. In this there is little or no 
fever; the patient seems convalescent so far as regaining strength and 
colour are concerned; but cough, dyspnoea, and rapid respiration con- 
tinue. The chest shows no change in signs from those of the acute stage. 
In chronic cases the general symptoms closely resemble those of tuber- 
culosis. There may be clubbing of the fingers, albuminuria, swelling of 
the feet, and often marked lateral curvature of the spine. 

Diagnosis. — The physical signs do not differ essentially from those 
present in serous effusion. If there are signs of fluid in the chest and 
the patient is under three years of age, the fluid is usually purulent; and 
from the third to the seventh year, pus is much more often found than 
serum. A marked leucocytosis always makes pus more probable. In 
eve^ case in which fluid is suspected the exploring needle should be 
used, because of the great importance of an early diagnosis. The skin 
should be surgically clean and the needle sterilised. Pus may not be 



558 DISEASES OF THE RESPIRATORY SYSTEM. 

found because the needle is too small, too short, or because it is intro- 
duced too far into the (.host ; for when the layer of pus is thin, the 
needle may he pushed through this into the lung. 

The physical signs upon which most reliance is to be placed are, 
marked dulness or flatness on percussion, feeble breathing, and displace- 
ment of the heart. When in a young child these signs are present, 
whether general or localised, a needle should be inserted, and if pus is 
not found at the first trial, repeated punctures should be made until 
the presence or absence of fluid is definitely settled. 

Empyema is most frequently confounded with unresolved pneumonia. 
The differential points are that in unresolved pneumonia the dulness is 
usually over a single lobe, rales or friction sounds are heard, and there is 
no displacement of the heart ; empyema may give flatness over the whole 
lung, or over the lower half of the chest in front and behind, rales and 
friction sounds are absent over this area, and the heart is usually dis- 
placed. In both conditions we may get bronchial breathing and voice. 
The confusion of acute pneumonia or tuberculosis with empyema, gen- 
erally arises from placing too much reliance upon auscultation. In 
pleuro-pneumonia, with an excessive exudation of fibrin, the signs may 
be identical with those of empyema, except that the heart is not dis- 
placed. I have twice seen pulmonary tuberculosis, with caseation of an 
entire lobe, which gave signs that were identical with those of a sac- 
culated empyema. It is by the exploring needle, and by that alone, that 
empyema is positively differentiated from these pulmonary conditions. 

There are some other thoracic diseases from which the diagnosis may 
be even more difficult. A large pericardial effusion gives signs which 
are in some cases identical with those of empyema of the left side. 
Marked displacement of the heart to the right is always a strong point 
in favour of empyema ; besides, such pericardial effusions are extremely 
rare in young children. A pulmonary abscess of considerable size — also 
a rare condition — gives signs identical with those of localised empyema, 
and is only distinguished from it by autopsy or operation. Abscesses 
from broken-down tuberculous glands may give signs resembling those 
of localised empyema, and like an empyema may point between the ribs 
in the upper part of the chest. The constitutional symptoms of empy- 
ema may at times resemble typhoid fever or malaria; but it is dis- 
tinguished from them by the physical signs and by the examination of 
the blood. 

Prognosis. — The outcome of a case of empyema depends chiefly upon 
the age and general condition of the patient, the exciting cause, the dura- 
tion of the symptoms, the presence or absence of serious complications, 
and the treatment. The mortality in infants under one year, partic- 
ularly hospital cases, is very high — fully ninety per cent. It is dif- 
ficult to understand why these cases do so badly ; many of these children 



EMPYEMA. 559 

on admission are in excellent condition and do well for a week or more 
after operation. Then the temperature rises, the patients lose ground 

rapidly and die of exhaustion at the end of the second or third week. 
Their inability to expand properly the compressed lung lias alw 

seemed to me an important factor, as this condition is almost invariably 
found at autopsy. Very seldom is there trouble with drainage. Em- 
pyema in children over two years old seen reasonably early and receiv- 
ing proper treatment, almost invariably terminates in recovery, unless 
the disease is double or serious complications exist. The best results are 
seen in the cases that follow pneumonia. Pneumococcus and staphylo- 
coccus cases have a better outlook than those due to the streptococcus. 
Tuberculosis before the seventh year is an exceedingly infrequent cause, 
and gangrene of the lung and general pyaemia are both rare causes in 
early life. It is these three conditions that make the prognosis of the 
disease in adults so serious. Great delay in operation makes the prog- 
nosis worse, because the more difficult the expansion of the lung the more 
tedious is the disease, and the greater the likelihood of a sinus remain- 
ing. With proper early treatment these patients not only recover, but 
in most cases the recovery is surprisingly complete. Retraction of the 
chest and its resulting lateral curvature of the spine are rare, and seen 
only in neglected cases. In very many cases, in which a reasonably early 
operation was done, it is impossible, after the lapse of two or three 
years, to detect any difference whatever in the physical signs of the two 
sides of the chest. There are few serious diseases the treatment of which 
is more satisfactory than that of acute empyema in older children. 

Spontaneous recovery in empyema may take place by absorption ; but 
this is so rare that it is not to be expected. The pus may be evacuated 
spontaneously through a bronchus, rupture having taken place through 
the visceral pleura. When this occurs, a large amount of pus may be 
coughed up in a few hours, usually followed by immediate, but not 
always lasting, improvement. This is the most favourable of the natural 
terminations. External opening may take place, usually in the region of 
the nipple. There is an area of redness, then a fluctuating tumour, and 
finally the pointing of an abscess. The discharge may continue for 
months, or even for years. External opening rarely occurs until the dis- 
ease has lasted several months. Of 19 cases of empyema in children col- 
lected by Schmidt, in which a spontaneous discharge of pus occurred 
either externally or through a bronchus, there were 17 deaths and 2 
recoveries. Empyema may burrow behind the diaphragm into the ab- 
dominal cavity, appearing as a psoas abscess; it may burrow posteriorly 
into the lumbar region; it may rupture into the oesophagus, or through 
the diaphragm into the peritoneal cavity. All these conditions, how- 
ever, are very rare. The chances of spontaneous cure in empyema are 
small. Of 32 cases, reported by Rilliet and Barthez, which received 



560 DISEASES OF THE RESPIRATORY SYSTEM. 

do Burgical treatment, ''1 proved fatal. The statistics of empyema be- 
fore t ho genera] adoption of surgical treatment are appalling. Patients 
were either worn out by the protracted suppuration, or died from amy- 
loid degeneration, pneumonia, or tuberculosis. 

Treatment. — The medical treatment relates to the patient only; the 
disease is always to be treated surgically. Like any other acute abscess, 
empyema requires free incision and drainage with proper aseptic pre- 
cautions. 

Aspiration as a means of cure is now seldom used. Unquestionably 
it sometimes suffices to cure empyema, most frequently when it is local- 
ised, and when the cause is the staphylococcus. How often this occurs 
is shown by the following statistics : Of 139 cases which I collected that 
were treated by aspiration, 25 were cured, 8 of these by a single aspira- 
tion; 13 died, and the remaining 101 were afterward subjected to other 
treatment. The objections to aspiration are, that it is not possible to 
remove all the pus; that it affords no opportunity for the removal of the 
large fibrinous masses; besides, there is the danger, especially with re- 
peated aspirations, of puncturing the lung and producing pneumothorax. 
Simple aspiration, therefore, is to be advised in children only for tem- 
porary relief when the amount of fluid is large and the symptoms are 
urgent. Aspiration, followed by the injection of formalin and glycerine, 
is not, from my experience, to be recommended. Likewise, the proced- 
ure of continuous aspiration, as proposed by Bryant, I have found in in- 
fants equally unsatisfactory. 

Incision and Drainage. — In many cases it is preferable to delay 
incision until the period of most acute inflammation has subsided, 
as shown by lower temperature and stationary physical signs. This 
is usually seen two or three weeks after the pleural invasion. Such 
delay is not admissible if either the local condition or the temperature 
points to a steady increase in the disease; nor when the general symp- 
toms indicate increasing prostration or sepsis. The dangers attendant 
upon general anaesthesia are considerable, and in most cases it is better 
not to employ it. I have known of four deaths on the table during 
operation, and in several other cases have seen very alarming symptoms 
occur. Chloroform is more to be feared than ether. It is well, when 
possible, to employ local anaesthesia. The most favourable point for 
incision is the posterior axillary line in the seventh intercostal space 
upon the right side, the eighth upon the left. In a case of localised 
empyema, the lowest point at which pus can be obtained by puncture 
should be chosen. The incision is made in the middle of the intercostal 
space. No matter what has been found by puncture on previous occa- 
sions, the exploring needle should always be used at the time of opera- 
tion and at the site of the incision before the latter is made. The in- 
cision should be only large enough to allow the introduction of two tubes 



EMPYEMA. 561 

side by side into the pleural cavity. The haemorrhage La wry rarely 
sufficient to require a ligature. It is, I believe, undesirable to attempt 
to empty the chest at the time of operation. A better plan is to insert 

the tubes at once and apply the dressings, allowing the pus to escape 
slowly. The drainage tubes should be of rubber, fenestrated, one-fourth 
to three-eighths of an inch in diameter and about three inches long. 

To secure them from slipping into the cavity, the outer end should be 
transfixed by a large safety-pin before introduction. 

Both the original operation and the subsequent dressings should be 
done with strict aseptic precautions on account of the danger of sec- 
ondary infection, the occurrence of which adds to the severity and pro- 
longs the course of the disease. After the third or fourth day the second 
tube may be omitted and the remaining one gradually shortened. Often, 
by the end of the fourth week, and sometimes before, the tube may be 
dispensed with altogether. The time of redressing and the removal of 
the tube is determined by the amount of discharge and the temperature. 

Simple incision with drainage I believe to be the preferable opera- 
tion for recent cases in infants. One advantage over rib resection is 
that it is shorter and altogether less of an operation, these factors being 
at times of considerable importance in very young and feeble children. 
Again, it can be done without an anaesthetic, and it has seemed to me 
that pulmonary expansion took place with greater facility than when 
the much larger opening into the chest was made. Finally, in a large 
number of cases, it gives all the room needed for drainage. There are, 
however, some disadvantages. The smaller opening may not give ade- 
quate room for the removal of large masses of fibrin. In old cases, par- 
ticularly, it not infrequently happens that after the chest has been 
emptied the ribs become so closely approximated that but little space is 
left, and the drainage tubes are pinched. Furthermore, the contact of 
the tubes may lead to erosion and superficial necrosis of the adjacent 
ribs, sometimes to exostoses. While, therefore, simple incision with 
drainage is to be preferred in the case of infants, for all other patients 
the resection of a rib seems desirable and advantageous. The removal 
of an inch of rib is usually all that is necessary. 

Kenyon's method of continuous drainage into a wash-bottle below 
the water level, has much to commend it especially for infants. The 
opening made into the chest is a small one admitting only a single tube. 
The wound is tightly packed about the tube so as to admit no air. The 
thoracic tube is connected by several feet of rubber tubing with the 
wash-bottle which contains a sterile salt solution. This bottle is sus- 
pended beneath the patient's bed or placed upon the floor. The char- 
acter and the amount of discharge can thus readily bo seen. As the 
tube need not be changed for several days the child is spared the fatigue 
and distress of frequent dressings. The small opening into the chesl is 
37 



562 



DISEASES OF THE RESPIRATORY SYSTEM. 



of considerable advantage in preventing the admission of air; it thus 
diminishes the danger of secondary infection and favours the expansion 
ol* the lung. Should the tube become Mocked it can be cleared by rais- 
ing the bottle and allowing the fluid to flow into the chesl and then 
siphoning it out. The bottle is emptied once or twice a day and the 
air is excluded by clamping the tube meanwhile. 

Washing oul the pleural cavity is indicated in cases in which 
the pus is foul. A single washing for the purpose of removing fibrin is 

the routine practice of some sur- 
geons. For this a warm, sterilised 
salt solution should be used. Per- 
sonally, I have seldom found this 
necessary. Repeated irrigations 
should not, I think, be employed. 
The usual duration of the dis- 
charge in cases treated by simple 
incision is from three to six 
weeks, the average heing about 
five weeks. 

A persistence of temperature 
or a fresh rise after operation most 
frequently indicates defective 
drainage, generally due to block- 
ing of the tube; but this is not 
always the case. It may be due 
to pneumonia, either a continu- 
ance of the old jDrocess or the 
lighting up of a new one, to ab- 
scess of the lung, to empyema of 
the opposite side, to pericarditis, 
or to some cause outside the chest, 
very frequently otitis. The mis- 
take is often made of allowing 
the tube to remain for too long a 
time, so that a sinus is kept open 
which would otherwise close. 

In chronic cases, or those 




Fig 



96. — Deformity after an Old Em- 
pyema of the Left Side for which 
Estlander's Operation was Per- 
formed. Portions of five ribs were re- 
moved . (From a photograph seven years 
after operation.) 



which have been long neglected, 
some further operative treatment 
is often necessary. The lung is so 
bound down by firm adhesions 
that further expansion is impos- 
sible, and even after the chest has receded to its utmost, so that the ribs 
are in contact, there still remains a cavity which can not close. For such 



EMPYEMA. 



563 



cases the only hope is an operation by which portions of several ribs are 
removed, thus allowing a greater collapse of the chest wall. This is 

known as thoracoplasty, or Estlander'k opcm/ion. The operation is of 

itself a serious one, and 

only to be advised as a last 

resort in inveterate cages. 

Such an operation is, of 

course, always followed by 

very great deformity (Fig. 

96). 

Methods of Inducing 
Expansion of the Lung. — 
In most of the cases, partic- 
ularly the recent ones, com- 
plete expansion of the lung 
takes place without any 
difficulty, the chief agent 
being the cough. In some 
Cases this may be insuffi- 
cient. The apparatus, de- 
vised by James, shown in 
the accompanying cut (Fig. 
97), serves at the same 
time as a toy for the child's amusement and as a most efficient means of 
inducing forced expiration. One bottle is placed a few inches higher than 
the other, and the child blows a coloured fluid from the lower into the 
higher bottle, allowing it to siphon back. Blowing soap bubbles often 
answers the same purpose. 




Fig. 97. 



-James's Apparatus for Expanding the 
Lung after Empyema. 



SECTION V. 
DISEASES OF THE CIRCULATORY SYSTEM. 

CHAPTER I. 
PECULIARITIES OF THE HEART AND CIRCULATION IN EARLY LIFE. 

The Foetal Circulation. — During the latter part of foetal life the cir- 
culation may be briefly described as follows: The purified blood comes 
from the placenta through the umbilical vein. Entering the body, it 
divides at the under surface of the liver into two branches, the smaller 
one, the ductus venosus, communicating directly with the inferior vena 
cava; the larger branch joining the portal vein, so that its blood trav- 
erses the liver, and then enters the inferior vena cava through the hepatic 
vein. From the inferior vena cava the blood enters the right auricle, like 
that returned from the head and upper extremities by the superior vena 
cava. A part of the blood now passes directly into the left auricle through 
the foramen ovale; the remainder, through the tricuspid orifice into the 
right ventricle. As the requirements of the pulmonary circulation are not 
great, only a small part of the blood is sent through the pulmonary artery 
to the lungs ; the greater portion passes from the pulmonary artery through 
the ductus arteriosus into the aorta, joining here the blood from the left 
ventricle. The blood thus finds its way from the right heart to the left, 
only in small part by way of the lungs, the greater part passing directly 
from the right auricle to the left, or from the right ventricle into the aorta 
through the ductus arteriosus. From the aorta, the blood reaches the 
placenta through the umbilical arteries, which are a continuation of the 
hypogastric arteries, which in turn are given off from the internal iliacs. 

Changes in the Circulation at Birth. — With the ligation of the um- 
bilical cord, the circulation through the umbilical vein and arteries and 
the ductus venosus ceases. With the establishment of respiration and 
the consequent increased demands made by the pulmonary circula- 
tion, the blood ceases almost at once to pass through the ductus arterio- 
sus, and very soon through the foramen ovale. The umbilical vessels 
during the first few days of life are filled with small thrombi, which be- 
come organised. By the end of the first week, these vessels, as well as the 
ductus venosus, are usually closed at their extremities, although they may 
remain patulous throughout the greater part of their extent for several 
weeks. They subsequently atrophy to the condition of small fibrous 
564 



HEART AND CIRCULATION IN EARLY LIFE. 



r>(\r> 



cords. For some weeks before birth the circulation through the foramen 
ovale is slight, il being gradually obstructed by the growth of a septum 
which Dearly fills the space at birth. After the first week of extra-uterine 
life very little, if any, blood passes through it, although complete closure 
of the foramen often does not take place until the middle of the first year. 
In fully one-fourth of the autopsies 1 have made upon infants under >i\ 
months old, there have been found minute openings at the margin of the 
foramen ovale, but they are usually oblique, and closed by the valvular 
curtain so as effectually to obstruct the current of blood. The ductus arte- 
riosus is first closed by a clot, which becomes organised and blends with 
the products of a proliferating arteritis. It is rarely found open after the 
tenth day, and by the twentieth it is almost invariably obliterated. 

The Pulse. — The pulse in early life is not only more frequent, but it 
is very much more variable than in adults. The following is the average 
pulse-rate in healthy children during sleep or perfect quiet: 

Six to twelve months 105 to 115 per minute. 

Two to six years 90 " 105 " 

Seven to ten years 80 " 90 " " 

Eleven to fourteen years 75 " 85 " " 



The pulse is a little more frequent in females than in males, and more 
frequent when sitting than when lying down. Muscular exercise or ex- 
citement increases the pulse-rate by from twenty to fifty beats. Very 
trivial causes disturb not only the frequency but the force of the pulse. 
The pulse in young infants may be irregular even in health and during 
sleep. When rapid, it is frequently irregular without special significance. 
No dicrotism is seen in the pulse wave of early infancy. 

The circulation is much more active in infancy than in later child- 
hood; thus, according to Vierordt, the entire round of the circulation is 
accomplished in the newly born in twelve seconds; at three years, in 
fifteen seconds; in the adult, in twenty-two seconds. 

Size and Growth. — The relative size of the heart is slightly greater in 
infancy than in later life, it being smallest at about the seventh year. 
The average weight at the different periods of life is as follows : ' 



Age. 


Ounces. 


Grammes. 


Ratio to body 
weight. 


Birth 


0.50 

1.25 
1.87 
2.25 
2.80 
5.84 
8.50 


,4] 
351 
53 f 

64 J 

80 
166 
241 




1 year 


1 to 225 


2 years 




3 " 




7 " 


1 to 280 


14 " 


1 to 222 


Adult , 


1 to 226 



1 The figures in infancy are from one hundred and fifty-five observations made in 
the New York Infant Asylum; the others are taken from Sahli. 



566 DISEASES ov THE CIRCULATORY SYSTEM. 

The growth o( the heart is rapid during the first three years, and 
nearly proportionate to thai of the body. It is slowest from the third 
to the tenth year, and most rapid from the eleventh to the fifteenth 
year. At birth, the thickness of the right ventricle is very nearly the 
same as thai o( the left, the ratio being 6:7. The left ventricle, how- 
ever, grows very much more rapidly than the right, so that at the end 
of the second year the ratio is 1:2, which is nearly that of the rest of 
childhood. 

Position of the Apex Beat. — In the infant the heart is placed some- 
what higher, and occupies a position a little nearer the horizontal than 
in the adult. This is partly due to the higher position of the dia- 
phragm. The apex beat is therefore higher and farther to the left than 
in adult life. According to the observations of Wassilewski and Starck, 
whose combined examinations with reference to this point were made 
upon over 2,100 children, the apex beat is, as a rule, outside the mam- 
mary line until the fourth year; if it is less than one-third of an inch 
beyond the nipple, it can not be considered abnormal. From the fourth 
to the ninth year, the apex beat is in or near the mammary line. After 
the thirteenth year, under normal conditions, it is invariably within 
that line. During the first year the apex beat is usually found in the 
fourth intercostal space; from the first to the seventh year, it is found 
with about equal frequency in the fourth and the fifth spaces; after the 
seventh it is usually, and after the thirteenth year it is always, when 
normal, in the fifth space. The position of the apex beat may be con- 
siderably modified by severe deformities of the chest resulting from 
rickets, Pott's disease, or lateral curvature of the spine. 

Examination of the Heart. — Inspection. — Bulging of the praecordia is 
a frequent and important sign of cardiac disease during childhood. The 
cardiac impulse is generally weaker than in the adult, and often it is 
difficult to locate the apex beat owing to the thick layer of adipose tissue 
covering the chest. 

Palpatio?!. — This is usually a much more satisfactory method than is 
inspection for determining the position of the apex beat. For this pur- 
pose the child should be in the sitting posture, with the body inclined 
slightly forward. Great displacement of the apex beat is always signifi- 
cant, and should lead one to suspect pleuritic effusion; lesser degrees of 
displacement to the left indicate hypertrophy, especially of the left ven- 
tricle; to the right, hypertrophy of the right ventricle. 

Percussion. — This is best done by means of the percussion hammer. 
A light blow should be used, on account of the thinness and elasticity of 
the chest walls. In percussing the heart, changes in the percussion 
note are generally better appreciated if .one proceeds from the lung 
toward the heart rather than in the opposite direction. The outline of 
the area of " relative " or " deep cardiac dulness," especially in small chil- 



CONGENTIAL ANOMALIES OF THE HEART. 567 

dren, is proportionately larger than in the adult. This may lead to the 
mistaken opinion that the heart is enlarged, when it is really of normal 
size. The upper boundary of this area is at the second interspace or tin- 
lower border of the second costal cartilage, at the left margin of the 
sternum; from this point the line of dulness extends in a curved direc- 
tion outward and downward, the extreme left limit being at or slightly 
beyond the mammary line at the fourth interspace. On the righl Bide 
the line of dulness extends downward from the Becond interspace in a 
slightly curved direction along the parasternal line. The lower border 
is indeterminable on account of the liver. 

The area of " absolute " or " superficial card ; ac dulness,*' or that part 
of the heart uncovered by the lung, resembles in shape the same area in 
the adult, but it is relatively larger. 

Auscultation. — This is of little value unless the child is quiet. For 
an accurate diagnosis the stethoscope is indispensable, hut auscultation 
should always be practised with the naked ear as well. The rhythm and 
rapidity of the child's heart action are much more easily disturbed than 
are the adult's, and such disturbances are consequently much less sig- 
nificant. The rapidity of the heart in infancy is ordinarily so great as 
to make it difficult to distinguish between diastolic and presystolic 
murmurs. Normally, the loudest sound is the first sound at the apex ; 
the weakest sound is the second sound at the aortic orifice. 

In consequence of the small size and the thin walls of the chest, all 
sounds, both normal and pathological, appear relatively louder than in 
the adult, and the area of diffusion is therefore much greater. Thus it is 
a frequent occurrence for murmurs to be heard all over the chest both in 
front and behind. 

Reduplication of the heart sounds, in consequence of the valves of 
the two sides not closing exactly together, is not uncommon in children, 
and may be due simply to excitement. During the first four years of 
life nearly all the abnormal murmurs heard are systolic. 

Accidental murmurs may be due to ana?mia and other blood condi- 
tions, and, although not so common as in older patients, they are by no 
means rare even in infants. 



CHAPTER II. 

CONGENITAL ANOMALIES OF THE HEART. 

Etiology. — Of the causes of congenital cardiac disease little is defi- 
nitely known. It occurs more often in first-born children than later 
ones; 16 of 50 cases being in first children (Still). It is often associated 
with other forms of imperfect development, notably of the brain, as 



568 



DISEASES OV THE CIRCULATORY SYSTEM. 



in Mongolian Idiocy. An attempt has been made to connect cardiac 
malformations with syphilis. A syphilitic family history is very sel- 
dom found. But Wart h in has lately brought forward additional reason 
for suspecting syphilis since he has found that some of these cases give 
a positive reaction to the Wassermann test. Further observations are 
needed on this point. There has not been adduced any evidence to show 
that rheumatism plays a part. 

Lesions. — The congenital anomalies of the heart may be grouped 
under three general heads: 

1. Malformations resulting from imperfect development of certain 
parts of the heart, most frequently one of the septa. Either the ven- 
tricular or the auricular septum may be affected, or that dividing the 
pulmonary artery from the aorta. Such failure in development per- 
petuates conditions which are normal in the early months of foetal life. 
There may also be atresia of any one of the orifices, absence of one or 
more of the valvular leaflets, or of any one of the large vessels. 

2. The results of foetal endocarditis. The effects of this condition 
vary according to the time of its occurrence. It is almost invariably of 
the right side, most frequently affecting the pulmonic valves. Valvular 
disease in foetal life leads not pnly to hypertrophy and dilatation, but 
also interferes with the normal development of the heart by preventing 
the closure of the auricular or ventricular septum or the ductus arterio- 
sus, these being kept open by way of compensation. 

3. Persistence of fcetal conditions, such as the foramen ovale or duc- 
tus arteriosus. This may be the result of valvular disease, as previously 
stated, or of some condition of the lungs, such as atelectasis. 

In the following table are given the lesions found in two hundred 
and forty-two cases, which I have collected from medical literature: 



Frequency of the different lesions in 2I/.2 autopsies upon cases of congenital 

cardiac anomaly. 

Defect in the ventricular septum 149 cases; the only lesion in 5 cases. 

Defect in the auricular septum, or patent fora- 
men ovale 126 

Pulmonic stenosis or atresia 108 

Patent ductus arteriosus 68 

Abnormalities in the origin of the great vessels. 45 

Pulmonic insufficiency 17 

Tricuspid insufficiency 6 

Tricuspid stenosis or atresia 3 

Mitral insufficiency 1 

Mitral stenosis or atresia 6 

Aortic insufficiency 1 

Aortic stenosis or atresia 6 

Transposition of the heart 2 

Ectocardia 1 



tt ti tt tt 


" 9 


tt a a a 


" 6 


tt tt it it 


" 3 


it it a a 


" 


a a tt it 


" 


tt it tt tt 


" 


it tt it tt 


" 


tt a it it 


" 


tt tt tt a 


" 


a tt a n 


" 


it a ti tt 


" 


a ti tt tt 


" 


a tt a tt 


" 



CONGENTIAL ANOMALIES OF THE HEART. 



569 



The most frequent associated lesions. 

Pulmonic stenosis with defect in the ventricu- 
lar septum 92 cases; the only lesions in 20 oases. 

Pulmonic stenosis, with defect in the auricular 

septum 52 " " " " " 8 

Defects in both septa 82 " " " " "17 " 

Pulmonic stenosis with defects in both septa. . 36 " " " " " 21 " 

From this table it will be seen that, in the great majority of i 
several lesions are present, the most frequent combinations being pul- 
monic stenosis with defective ventricular septum, pulmonic stenosis 
with defective aurieular septum, the three lesions associated, or the first 
two with a patent ductus arteriosus. Stenosis of the isthmus of the 
aorta, although not noted in this series, is not a very uncommon lesion; 
the obstruction is in the arch of the aorta beyond the point where the 
large vessels are given off. 

D.efcct in the Ventricular Septum. — This is the most frequent lesion 
in congenital cardiac disease, and in half the cases was associated with 
pulmonic stenosis. The defect is 
generally at the upper part of the 
septum (Fig. 98). It is usually 
from one-fourth to one-half an 
inch in diameter, but not infre- ^_ „ . _. _ 

quently there is a large defect, Bflk ^M 

and the septum may be entirely ^T felHf^ J 
absent, the heart then consisting 
of but three cavities — two auri- 
cles and one ventricle. If the h; i 
auricular septum also is want- P Jpfa V V ' 

ing, as may be the case, the heart U ^\ v \ 
has but two cavities. Frequently Ml ^^tv^ ^ 

there are also abnormalities in ^^^^^^/^^K^^ 
the origin of the great vessels. 
The pulmonary artery and the 

aorta may be given off from the 

. Fig. 98. — Congenital Cardiac Disease. 

common ventricle, or the aorta The left vcntr i c i e i s shown with a defect 

may arise partly from One ven- in the ventricular septum, the opening l>e- 

x • "i t , i " p ii _4.i ing just beneath the aortic valve. (From 

tncle and partly from the other. a J^ dying fa thc Babies , Ho spital.) 

If pulmonic stenosis or atresia 

is present, the opening in the ventricular septum is conservative, afford- 
ing a channel for the passage of blood from the right to the left side 
of the heart. 

Patent Foramen Oral,', or Defect in the Auricular Septum. — Al- 
though this is one of the most common congenital malformations, it is 
not one of the most important. It rarely occurs alone, but is frequently 




570 DISEASES OF THE CIRCULATORY SYSTEM. 

found with pulmonic stenosis or a defect in the ventricular septum. 
Small oblique openings in the auricular septum — usually at the foramen 
ovale — are not infrequently met with in autopsies upon young infants, 
but they are of no importance. In pathological conditions the opening 
is from one- fourth to one inch in diameter, and there may be more than 
one opening. A defect in this septum is frequently secondary to pul- 
monic stenosis. 

Patent Ductus Arteriosus. — As a solitary lesion this is rare, but it is 
frequently associated with pulmonic stenosis, usually with a defect in one 
or both septa. It is then one of the channels by which the blood may 
find its May to the lungs when the pulmonary orifice is obstructed. It 
is not a malformation, hut simply the persistence of a fcetal condition 
usually necessitated by other changes in the heart. But the direction of 
the blood current is the opposite of that which exists in foetal life. 

Pulmonic Stenosis. — This is one of the most frequent and most im- 
portant lesions. It may be due to fcetal endocarditis, or to a malfor- 
mation. If the former, there is usually stenosis; if the latter, there may 
be atresia. It is often a primary lesion, and when marked it is al- 
ways accompanied by other changes, most frequently by a defect in one 
or both septa or by a patent ductus arteriosus. This is important, as 
being more constantly associated with cyanosis than is any other con- 
genital lesion. Most of the children who live beyond six or seven years 
with cyanosis have this lesion, always accompanied by others of a com- 
pensatory character. The amount of obstruction varies from a slight 
narrowing of the orifice to complete atresia. The seat of obstruction 
may be at the pulmonic orifice, in the conus arteriosus, or in the pul- 
monary artery just beyond the valves. If there is atresia, the pulmonary 
artery is very small, and may be rudimentary. 

Pulmonic Insufficiency. — This lesion is relatively rare. It is usually 
the result of foetal endocarditis, but there may be absence of the pul- 
monary valve. It is most frequently associated with a defect in the ven- 
tricular septum. 

Tricuspid, mitral, and aortic disease are relatively infrequent and 
usually seen in cases with multiple defects. Atresia or stenosis is much 
more common than insufficiency. 

Abnormalities in the Origin of the Large Vessels. — These are quite 
frequent; but, as will be seen from the table, they are always associated 
with other lesions. Three forms are seen : ( 1 ) Transposition of the large 
vessels — the pulmonary artery is given off from the left, and the aorta 
from the right, ventricle. (2) Both arteries arise from a common 
trunk. This is usually due to an incomplete development of the lower 
part of the septum dividing the two arteries. Usually the pulmonary 
artery appears to be a branch of the aorta. This condition is fre- 
quently associated with other abnormalities, often with so large a defect 



CONGENTIAL ANOMALIES OF THE HEART. 571 

in the ventricular septum that there lb really but one ventricle. (:5) The 
aorta has an abnormal origin, arising from the right ventricle, or partly 
from both ventricles. This also is associated with a large clefed in the 
ventricular septum. When described as arising from both ventricles, the 
aorta is usually given off directly above the lino of the septum. 

An abnormality in the number of valvular segments is quite fre- 
quent, but seldom impairs the valve's function. In rare cases a valve is 
rudimentary, and it may be absent, generally at the pulmonic or tri- 
cuspid orifice. Absence of the right auricle and absence of the pericar- 
dium have been recorded; also opening of the pulmonary veins into the 
right auricle, and a single pulmonary artery. In one case in the series 
there was ectocardia, this being associated with a congenital fissure of 
the sternum. I once saw a very remarkable instance of congenital car- 
diac displacement; the heart was situated in the abdominal cavity. Its 
pulsations could be plainly seen and felt just above the umbilicus. 
There was a large umbilical hernia, a congenital defect of the abdom- 
inal walls, and undoubtedly also an opening in the diaphragm. 1 

Transposition of the heart, or true dextro-cardia, was recorded but 
twice in this series of cases. It was, however, simulated in several 
others, including one of my own, where the apex beat was to the right 
of the sternum. There was in this case great hypertrophy of the right 
ventricle with a rudimentary ventricular septum. 

Secondary Lesions. — In congenital malformations the right heart is 
usually found hypertrophied, since there are present one or more of the 
foetal conditions in which the greater part of the work is thrown upon 
the right ventricle. Such hypertrophy is in most cases accompanied by 
some dilatation. Changes in the wall of the left heart alone are exceed- 
ingly rare. In four cases there w r as evidence of malignant endocarditis, 
which was the cause of death, all but one of these patients being adults. 

Symptoms. — The symptoms of congenital cardiac disease are usually 
manifested soon after birth. Of 128 cases in which the time of the first 
symptoms was noted, they were congenital, or appeared during the 
first month, in 85; after one month and during the first year, in 18; 
from one to sixteen years, in 15; while in 10 no symptoms were observed 
until after puberty. Congenital cardiac disease is one of the causes, but 
not a frequent one, of death during the first days of lite. 

The most striking objective symptom is cyanosis. This is present 
in most of the severe cases; but, considering all varieties, cyanosis is 
more often absent than present, and it may be absent even witli serious 
lesions. It may be slight and noticed only upon exertion, as upon 
coughing or crying, or it may be intense and constant, giving the skin 
a dark, leaden colour, and the mucous membrane of the mouth a rasp- 

1 The Medical News, December 11, 1S97. 



572 DISEASES OF THE CIRCULATORY SYSTEM. 

berry hue. The view thai cyanosis depends upon an admixture of 
arterial and venous blood is generally discredited. In the great ma- 
jority of the cases at least, the explanation is a deficient oxidation of 
the blood in the lungs, owing to some interference with the pulmonary 
circulation. In sixty-three per cent of the cases with cyanosis in the 
scries, there was found pulmonic stenosis or atresia, or a small pulmonary 
artery. Cyanosis is o( much value in diagnosis, as in acquired cardiac 
disease it is rarely persistent. The degree of cyanosis and its con- 
stancy are of some importance in determining the gravity of the lesion, 
although cyanosis alone is not to be depended upon. 

Another frequent symptom is the enlargement of the terminal 
phalanges known as clubbed or "drum-stick" ringers (Fig. 99) and 




Fig. 99. — Clubbing of the Fingers in Congenital Heart Disease. 
(From a boy five years old.) 

toes. This almost invariably accompanies cyanosis, and is generally pro- 
portionate to it. The enlargement, which usually involves all the 
phalanges, is probably due to venous obstruction. Occasionally there 
are seen dyspnoea, oedema of the face or lower extremities, dropsy of 
the serous cavities, and haemorrhages, particularly haemoptysis and 
epistaxis. 

There is generally marked dyspnoea on exertion in the cases in which 
cyanosis is present; but in most of those without cyanosis there is no 
dyspnoea, and, in fact, no objective or subjective symptoms, even though 
the murmur may be very loud. The majority of the cyanotic cases are 



CONGENTIAL ANOMALIES OF THE HEART. 573 

undersized and develop slowly; in them the problem of nutrition is a 
difficult one. 

In cases accompanied by cyanosis, or with obstruction to the pulmo- 
nary circulation^ a polycythemia is present. The increase in the Dumber 
of red cells is generally proportionate to the cyanosis; the average of fif- 
teen cases studied in my clinic by Dr. I. S. Wile was 7,495,000; the 
highest was 12,480,000. The haemoglobin is usually correspondingly 
increased. In the series mentioned the average was l'»< per cent, the 
highest heing 130. The number of white cells is changed very slightly, 
if at all; the average in my cases was 10,200, which disproves the theory 
of blood concentration. The best explanation of the polycythemia 
seems to be that it is compensatory, and that the blood hypertrophies 
like other tissues. The blood-forming organs are stimulated to greater 
activity by the demands of the tissues for oxygen. The quantity of blood 
remains the same, but the number of red cells and the haemoglobin, and 
consequently the oxygen-carrying power, are yery greatly increased. This 
in part compensates for the smaller amount of blood that can traverse 
the lungs and there become oxygenated. 

Diagnosis. — The most important diagnostic features are cyanosis, the 
presence of a loud murmur, and signs of enlargement of the right heart. 

Murmurs are present in fully nine-tenths of the cases, the most 
characteristic being a systolic murmur, loudest at the left border of the 
sternum in the second or third intercostal space, and widely diffused, 
often being audible all over the chest. The point of maximum intensity 
is important for diagnosis. In the great majority of cases only a single 
murmur is heard. A systolic murmur is usually due to pulmonic stenosis, 
deficient ventricular septum or aortic stenosis, very rarely to mitral or 
tricuspid regurgitation. Since these conditions are very often associated, 
it is difficult to tell upon which one the murmur depends. 

A patent ductus arteriosus usually gives a prolonged, almost con- 
tinuous, murmur with systolic intensification, which is loudest in the sec- 
ond or third left interspace. In a young child, a loud murmur at the 
base of the heart with cyanosis, almost always means congenital disease. 
A thrill is often present but it is not important for a diagnosis. 

Enlargement of the right heart, chiefly from ventricular hypertrophy, 
is present in most of the cases. 

A diagnosis of the precise nature of the malformation is very difficult, 
and in the great majority of cases only a probable diagnosis is possible. 
Nearly all the cases are complex, and the variety of combinations is very 
great. A study of the histories and autopsies of the cases in this series 
reveals many apparently contradictory facts. Loud murmurs are some- 
times heard which are difficult to explain by the lesions, and murmurs 
may be absent when there is every reason from the post-mortem findings 
for expecting their presence. With reference to the other conditions, I 



r>74 DISEASES OF THE CIRCULATOR!? SYSTEM. 

can not do better than give the more frequent clinical symptoms with 
the results of the autopsies m the series of cases which I have collected. 

.1 Systolic Murmur at the Base with Cyanosis. — This was the most 
common combination met with, and was present in about one-third of 
the entire number. In over eighty per eent of the cases with these 
symptoms, pulmonic stenosis was found. The remainder were compli- 
cated cases o( quite a wide variety. Pulmonic stenosis was usually 
associated with a delect in one of the cardiac septa, or a patent ductus 
arteriosus. 

.1 Systolic Murmur without Cyanosis. — In this series of autopsies 
this was not a frequent combination, being noted but six times. It is 
usually dependent upon a defect in the ventricular septum without pul- 
monic stenosis. Clinically, however, this is more often seen, in fact it 
is one of the most common types. The murmur is generally loudest 
at the left margin of the sternum at the third space. There is a striking 
absence of all other symptoms. I have watched a number of such pa- 
tients grow to maturity and go through serious attacks of illness without 
showing any symptoms referable to the heart. 

A Systolic Murmur at tlie Apex with Cyanosis. — Of the six cases with 
this combination, all were examples of complex malformation, the most 
frequent lesions being a defect in the auricular septum, transposition of 
the great vessels, and patent ductus arteriosus. 

Cyanosis without murmurs was noted fourteen times. It usually in- 
dicates either pulmonic atresia or the transposition or irregular origin 
of the great vessels, but is sometimes seen when lesions, such as usually 
give murmurs, are found at autopsy. 

Diastolic murmurs were heard in two cases, and depended upon pul- 
monic insufficiency. 

Absence of both cyanosis and murmurs was recorded in five cases. 
The lesions found were: atresia of the aorta, both arteries arising from 
the right ventricle, or defective septa. 

The only cases, therefore, in which a fairly certain anatomical diag- 
nosis can be made are those of pulmonic stenosis with a deficient ven- 
tricular septum. 

Diagnosis of Congenital from Acquired Disease. — Congenital dis- 
ease may be suspected if the patient is under two years of age; if there 
is no history of previous rheumatism; if the murmur is atypical in its 
location, character, or transmission; if there is a very loud murmur at 
the base or over the body of the heart, and if there is evidence of enlarge- 
ment of the right heart. If cyanosis and clubbing of the fingers are 
present the diagnosis i> almost certain. 

Especially difficult are the cases without cyanosis seen in older chil- 
dren. But absence of hypertrophy of the left ventricle, continued absence 
of subjective symptoms, even with a very loud murmur, and a lesion 



CONGENTIAL ANOMALIES OF THE HEART. 575 

which docs not increase, all point strongly to a congenital malfor- 
mation. 

Diagnosis of Congenital from Accidental Murmurs. — This is often a 
more difficult matter than to decide between congenital and acquired dis- 
ease. From a murmur alone one should be very cautious in making a diag- 
nosis of cardiac malformation in a ?ery anaemic infant. Anaemic murmurs 
are systolic-, usually hash-, unaccompanied by enlargemenl of the heart; 
usually heard in the carotids, often in the subclavian arteries, bul arc 
seldom so loud as those due to malformations. In some cases it may he 
;sary to watch the progress of the case before deciding the question. 

In children from three to ten years of age it is not uncommon i<> 
find about the level of the nipple at the left border of the sternum a 
soft systolic murmur best heard on lying down, which, as it usually 
disappears, must he considered functional. It is easily mistaken for a 
congenital murmur. 

Prognosis. — Of 225 cases, 60 per cent were fatal before the end of 
the fifth year, and nearly one-half of these during the first two months; 
while sixteen per cent of the cases lived over sixteen years, and eight per 
cent over thirty years. The prognosis in cases without cyanosis is good; 
in many children the lesion has apparently little effect on the health or 
development. The prognosis is much worse in cases with cyanosis, and 
generally it is bad in proportion to the degree of cyanosis. The loudness 
of the murmur has no prognostic importance. 

In the cases fatal soon after birth the usual lesions are large defects 
in the septa, transposition of the great vessels, or pulmonic atresia. In 
five of twenty-three cases dying thus early, the heart had but two cavities. 
Lesions which are compatible with the longest life are minor septum 
defects, and pulmonic stenosis which can be compensated for by hyper- 
trophy of the right ventricle and in other ways. Many exceptional in- 
stances are recorded in which patients have lived a long time in spite of 
extreme deformities. One child with transposition of the pulmonary 
artery and aorta lived two and a half years. Tiedemann's case lived 
eleven years with a heart consisting of three cavities — two auricles and 
one ventricle — and with constant cyanosis. In three cases reported by 
Rokitansky, the patients lived over forty years with rudimentary auric- 
ular septa; cyanosis is not mentioned as being present. Gelpke's case 
had cyanosis, and lived twenty-seven years with rudimentary auricular 
and ventricular septa, and with no tricuspid opening. Patients with 
serious congenital cardiac lesions are especially susceptible to pulmonary 
diseases of all kinds and occasionally develop malignant endocarditis. 
Almost any acute illness may prove fatal. 

Treatment. — These patients are prone to develop at times attacks 
resembling angina pectoris, which are best relieved by amylnitrite ox 
by the use of morphine hypodermic-ally. No treatment is of the 



576 DISEASES OF THE CIRCULATORY SYSTEM. 

slightest avail in diminishing the amount of deformity or promoting the 
closure of any of the abnormal openings. All cases are to be treated 
Bymptomatically. 



CHAPTER III. 
PERICARDITIS. 

Inflammation* of the pericardium is uncommon in infancy and 
early childhood, only two cases being seen in 726 consecutive autopsies 
at the New York Infant Asylum. But in later childhood pericarditis 
is more frequent and more serious than the same disease in adults. 

Pericarditis is almost invariably a secondary disease, following (1) 
empyema or pleuro-pneumonia ; (2) acute rheumatism; (3) acute in- 
fectious diseases, especially scarlet fever ; (4) pyaemia; (5) tuberculosis; 
(6) local conditions. The relative importance of these causes differs 
with the age of the child. In infancy and early childhood nearly all the 
cases complicate disease of the lung or pleura, more frequently of the 
left side. After the fourth year rheumatism takes the first place as an 
etiological factor. Pericarditis is then generally associated with endo- 
carditis, and may precede or follow the articular manifestations of rheu- 
matism. Following scarlet fever, pericarditis often occurs in connection 
with nephritis or multiple joint inflammations. In typhoid fever also 
it is usually associated with pneumonia or joint lesions. Pyaemia may 
be a cause in the newly born, or it may occur in connection with disease 
of the bones or joints in older children; in both it is usually associated 
with similar lesions of other serous membranes. Tuberculous pericarditis 
is more frequent after the third year, and is generally secondary to pul- 
monary tuberculosis. Among the local causes may be mentioned trau- 
matism, ulceration of a foreign body from the oesophagus into the peri- 
cardium, disease of the sternum, ribs, or vertebrae, and' abscesses resulting 
from cheesy bronchial lymph nodes. 

Lesions. — Pericardial transudations, or an increase in the normal 
pericardial fluid, are met with in many conditions in which there is a 
very marked degree of anaemia, general dropsy, or a weak heart, partic- 
ularly of the right side. Generally from one and a half to two ounces 
of clear serum are found in the pericardial sac. 

Pneumococcus pericarditis is always acute and closely resembles in 
its lesions the inflammation of the pleura due to the same cause. In 
the milder cases there is seen only a fibrinous exudate. In the more 
common and more severe forms the visceral and parietal pericardium is 
covered with a thick coating of fibrin and pus (compare pleuro-pneu- 
monia), or more pus cells and serum may be poured out and the sac 



ACUTE PERICARDITIS. 577 

contain fluid pus. The amount is usually small, one-half i<> one ounce, 
but it may be as much as a pint. When the inflammation is excited by 
other pyogenic organisms, tne staphylococcus or the streptococcus, the 
lesions are similar to those just described 

In rheumatic pericarditis the inflammation may be a plastic one wiih 
a fibrino-cellular exudate (dry pericarditis) or sero-fibrinous (pericar- 
ditis with effusion). The inflammation generally begins at the baee of 
the heart and affects both the visceral and parietal layers. The quantity 
of fluid present is usually small, not exceeding two or three ounces; ex- 
ceptionally as much as a pint may he present. It may he clear or 
slightly turbid. More important than the pericarditis are the associated 
changes in the heart muscle. These are present in every severe case. 
To the myocarditis and consequent dilatation the most serious symptoms 
of pericarditis are due. 

Purulent pericarditis may he set up by a foreign body ulcerating into 
the sac, by the rupture of a mediastinal abscess, or by general pyaemia. 
Under these circumstances the process may be purulent from the outset. 
Any of the pyogenic bacteria may be found. 

External or mediastinal pericarditis is always associated with medi- 
astinal pleurisy, and results in more or less extensive adhesions of the 
pericardial and pleural surfaces, with an increase in the connective tissue 
of the mediastinum. This is often a tuberculous process. When severe, 
it may cause compression of the large blood-vessels, but seldom in any 
other way produce symptoms. With this form there is usually inflam- 
mation of the internal layer of the pericardium as well. Only inflamma- 
tion of the internal layer is ordinarily considered as pericarditis, the 
other form being preferably classed as mediastinitis. 

Pericarditis with an effusion of blood is very rare in children. It may 
occur from the rupture of organised adhesions or in certain blood states 
such as purpura, and very rarely in tuberculosis. 

With acute tuberculosis there is usually only a deposit of miliary 
tubercles, or there may be a small serous or sero-sanguinolent effusion. 
In chronic cases there may be a tuberculous inflammation with the for- 
mation of caseous nodules, new connective tissue, and extensive adhesions. 
This generally occurs in connection with pulmonary tuberculosis — some- 
times with tuberculous peritonitis. 

In any form of pericarditis complete recovery, so far as pathological 
conditions are concerned, is rare — if, indeed, it ever occurs. After a 
rheumatic pericarditis adhesions remain, which may he slight, but are 
often complete, causing entire obliteration of the pericardial sac. Such 
adhesions are followed by secondary changes. The growth and devel- 
opment of the heart are interfered with, and there 1 may be sumcienl 
pressure upon the coronary vessels to lead to degeneration of the mus- 
cular walls and chronic dilatation of the heart. 
38 



578 DISEASES OF THE CIRCULATORY SYSTEM. 

Symptoms. —A pericardia] transudation, or dropsy of the pericar- 
dium, is very rarely Large enough to make a diagnosis possible. 

External pericarditis is seldom recognised during life, there being no 
symptoms except those of the pleurisy with which il is associated* Occa- 
sionally there may be hoard, particularly if the inflammation is anterior, 
a pleuritic friction sound which is increased with the systole of the 
heart. The pulse may be weak during inspiration, and there may be an 
increased area ol' cardiac dulness. If the inflammation is chiefly posterior, 
it causes only the symptoms of mediastinitis, which is recognised prin- 
cipally by its pressure effects upon the great vessels. It may produce 
oedema o\' the face or of the lower extremities, ascites, enlargement of the 
liver and spleen, but rarely albuminuria. It is usually progressive, and 
lasts from a few months to two or three years, according to its cause. 

Pericarditis in infancy is usually overlooked, not only on account of 
its rarity, but also from the obscurity of its symptoms. When pericarditis 
develops at the height of an attack of pneumonia, as it usually does, 
there may be no new symptoms, or at most only increased prostration 
with perhaps a more rapid or slightly irregular pulse. On auscultation, 
if practised early, one may get pericardial friction sounds ; but these are 
masked by the pulmonary signs and in infants seldom made out. The 
most striking sign is that the cardiac sounds formerly distinct are now 
feeble and distant, at times almost inaudible. Later there may be in- 
creased dulness from pericardial effusion, or from dilatation. The phy- 
sician should be on the watch for it in infants with pleuro-pneumonia, 
especially of the left side. 

Rheumatic pericarditis affecting as it generally does older children 
is easier of recognition. Localised pain and tenderness are usually pres- 
ent and also a certain amount of embarrassment of the heart's action, 
manifested by precordial distress, palpitation, or a tumultuous heart 
action with a rapid and at times an irregular pulse. There is often vom- 
iting, dyspnoea, and a teasing, dry cough; there may be orthopncea and 
some cyanosis. Sometimes there is delirium. 

The earliest physical signs of pericarditis are friction sounds, which 
can generally be heard, though sometimes over only a small area, at 
the base of the heart. The sound is a double one; it is synchronous 
with the heart's movement, it is generally more circumscribed than 
an endocardial murmur and not so blowing in character. Very early 
there is an increase in cardiac dulness which may be considerable. It 
may extend as much as one and one-half inches beyond the riglit border 
of the sternum, and to the left one or two inches beyond the mammary 
line. (See Figs. 100 and 101.) It may be due to effusion or to dilata- 
tion with which effusion is easily and frequently confounded. In a case 
with early and rapidly developing dulness it is safe to assume that some 
dilatation is present. When there is considerable effusion the apex beat 



ACUTE PERICARDITIS. 



579 



is feeble and may be displaced upward. The cardiac sounds arc dimin- 
ished in intensity and may be almost inaudible. The area of dulm 
triangular or pear-shaped with the base below. With large effusion there 

may also be dulness to the left of the spine behind. Rotch's Bign of 
effusion, dulness to the right of the sternum in the fifth space, though 
often present is not entirely reliable. 

In cases«terminating fatally the progress of the disease is quite rapid, 
the entire duration being seldom longer than three or four weeks, and 




Fig. 100. — Pericarditis with Effusion. 
Anterior view, showing moderate disten- 
tion of the pericardium, especially to the 
right of the middle line; right border 
at A. Boy eight years old. 



Fig. 101. — Pericarditis with Effusion. 
Same patient as Fig. 100, but taken four 
days later. Great distention of the peri- 
cardium ; right border at B. Complete 
recovery by absorption. 



it may be much less. Pneumonia often develops toward the close. When 
ending in recovery improvement is very slow and it may be two or three 
months before the patient is out of bed, and a much longer time before 
even a moderate degree of health is established. 

Prognosis. — Acute pericarditis due to the pneumococcus in infancy 
almost invariably ends fatally and in older children this is the usual 
termination. Occasionally at the later age resolution may take place 
before pus forms, or the pyo-pericardium which ensues is successfully 
opened and drained. Purulent pericarditis from other causes is usually 
fatal. In rheumatic pericarditis the outlook for life is better, but this 
with its associated nryocarditis is without doubt the gravest manifesta- 
tion of rheumatism in early life. No complication is more to be dreaded, 
both on account of immediate and remote dangers. Of forty-eight cases 
of acute pericarditis reported by Still in which this supervened during 
endocarditis, forty proved fatal in the course of a few weeks. In patients 
who do not die from the disease the remote consequences by reason of 
adhesions and subsequent dilatation are very serious. 

Diagnosis. — Pericarditis is recognised by knowing when to look for 
it — in infants with pneumonia, in older children with rheumatism. The 



580 DISEASES OV THE CIRCULATORY SYSTEM. 

difficulties o\' diagnosis ot dry pericarditis are very much greater in young 
children owing to the very rapid action of the heart. Dry pericarditis 
is recognised by the friction sounds, which are best heard over the base 
and are to be differentiated from endocardial murmurs. Pericarditis with 
effusion is to be diagnosticated from dilatation of the heart and from pleu- 
ritic effusions. From dilatation, the diagnosis is very difficult in child- 
hood, hut tlu' recognition of small effusions is not essential, since the im- 
portant condition is the accompanying dilatation. Large effusions may he 
mistaken for a sacculated empyema of the left side, in the latter, however, 
the heart is generally crowded to the right. When empyema and pericar- 
ditis coexist, it may he impossible to recognise the condition. The diag- 
nosis between serous and purulent effusions can be made only by aspiration. 
Treatment. — In an attack of acute pericarditis the patient should be 
kept in bed, absolutely quiet, and an ice-bag used over the heart. A 
layer of thin flannel should be placed beneath the bag. During the 
acute stage it should be applied constantly with perhaps a few hours' 
omission during the night. To be effective much attention to detail is 
necessary. Some children will not tolerate ice and for them dry heat 
may be substituted. It often mitigates the pain. Counter-irritation by 
mustard from time to time is useful, but blisters should not be employed 
in children. Leeching is much used in England, not so much in this 
country as its merits warrant. Four or five leeches are applied over the 
sternum or liver. The especial indications • for leeches according to Still 
are cyanosis, marked dyspnoea, and a dilatation as shown by increase in 
the cardiac dulness. A rapid increase in dulness is to be regarded as 
mainly due to dilatation rather than effusion. Opium is, I think, of 
more value than any other drug. It has a steadying influence upon the 
excited heart, it relieves pain and also quiets the distressing cough. The 
form of administration is immaterial. The patient should be kept 
moderately under its influence throughout the active stage of the attack. 
Digitalis is sometimes useful, but must be used with caution. Alcohol 
is seldom indicated and has often done much harm in these cases. 
Strychnia and caffein are much to be preferred wdien symptoms of heart 
failure are present. In the rheumatic form anti-rheumatic remedies are 
indicated, though it is still a question whether they accomplish very 
much after a severe pericarditis is once fairly under way. Either sali- 
cylate of soda or aspirin may be used. Serous effusions usually subside 
under simple tonic treatment. With very large serous effusions aspira- 
tion may relieve distressing symptoms, after which the rest of the fluid 
may undergo absorption. If the exploring needle shows the fluid to 
he purulent, incision and drainage should be practised as in empyema. 
The results of aspiration are exceedingly unfavourable. " Of eighteen 
cases of aspiration of the pericardium collected by Keating, only four 
recovered. In puncturing the pericardium the point usually selected is a 



CHRONIC PERICARDITIS WITH ADHESIO 581 

Utile to the left of the border of the sternum in the fifth intercostal 

space, the needle being directed upward and outward. In cases which do 
not end fatally a prolonged period of rest in bed LS imperative on account 
of the dilatation. 

CHRONIC PERICARDITIS WITH ADHESIONS. 

This is not a very uncommon condition. It is usually general, hut 
may be localised. The youngest case which has come under my observa- 
tion was in a child sixteen months old, who died from acute broncho- 
pneumonia. The adhesions were old and general, the pericardial sac 
being completely obliterated. Chronic adhesive pericarditis may follow 
single or repeated attacks of acute rheumatic pericarditis ; it may be tuber- 
culous. The pericardium may become very greatly thickened and its 
cavity obliterated ; it may be adherent externally to the pleura, diaphragm, 
and chest wall. Other changes are usually present in the heart. It is 
often the seat of chronic myocarditis; the cavities are usually greatly 
dilated, and the heart walls much hypertrophied. Valvular lesions may 
be present 

Partial adhesions cause no symptoms by which they can be recognised, 
and even general adhesions sufficient to obliterate the pericardial sac 
may be found at autopsy when not suspected during life. This is one of 
the conditions in which, after it has led to considerable dilatation of the 
heart, sudden death sometimes occurs. Usually there is pallor, slight 
cyanosis, localised oedema of the chest and abdominal walls, and dyspnoea 
upon slight exertion. The liver and spleen are often enlarged and there 
may be ascites. These symptoms often lead to errors in diagnosis. 

The heart is almost invariably much enlarged, chiefly from dilatation. 
On inspection, there may be bulging of the chest wall, with a diffused 
and often feeble or absent apex beat. The characteristic signs are a 
systolic retraction of the chest at or near the apex of the heart, sometimes 
at the tip of the sternum. This is due to the external pericardial ad- 
hesions, and is often better appreciated by palpation than by inspection. 
It is followed by a rapid rebound, associated with diastolic collapse of the 
jugular veins. Pulsus paradoxicus may also be present. Percussion 
shows an increase in the cardiac dulness in all directions. The position 
of the apex and the percussion outline of the heart do not change with 
the posture of the patient, and the cardiac dulness is hut little affected 
by full inspiration. A systolic murmur is often present. The diagnosis 
of adherent pericardium always presents difficulties, but it can he made 
with tolerable certainty in a considerable proportion of cases. On 
account of the enlargement of the heart and the frequency of murmurs, 
it is usually mistaken for valvular disease 1 . The prognosis is very had. 
The lesion is a permanent one, and tends to increase The treatment is 
symptomatic. 



582 



DISEASES OF THE CIRCULATORY SYSTEM. 



CHAFTKK IV. 



ENDOCARDITIS AND VALVULAR DISEASE OF THE HEART. 



Endocarditis may occur even in foetal life. At this period it usu- 
ally affects the right side of the heart, and is one of the important causes 
of congenita] malformations. In infancy, acute endocarditis is exceed- 
ingly rare, not a single instance heing found in over one thousand autop- 
sies upon children under three years of age of which I have records. 
From the third to the fifth year it is not so rare, and after five years is 
quite common. 

The following tahle gives the age and sex in a series of cases of 
valvular disease observed by Dr. Crandall and myself : 



Age. 


i 

year. 


years. 


3 
years. 


4 

years. 


years. 


9 

years. 


7 
years. 


8 
years. 


9 

years. 


years. 


11 12 

years, years. 


13 
years. 


14 
years. 


l 

Totals. 


Males . . 
Females. 




1 
1 


2 
3 


2 
5 


4 

7 


6 
9 


4 
10 


9 
3 


8 
11 


6 
12 


5 
14 


7 
4 


6 
2 


1 

3 


55, or 38% 
90, "62% 


Total. 


1 2 

"1 


5 


7 


11 


15 


14 


12 


19 


18 


19 


11 


8 


4 


145 



The proportion of the sexes is very nearly the same as in my cases of 
rheumatism. Sturges, in 100 cases of chronic endocarditis, gives fifty- 
six per cent females and forty-four per cent males. 

Endocarditis is usually spoken of as secondary to rheumatism; it is 
rather to be regarded as a manifestation, often the first, of that disease. 
Of 117 cases in my own series, ninety-three, or eighty per cent, gave a 
history of previous rheumatism. Of the 31 cases which at the first 
examination gave no history of rheumatism, 8 subsequently developed 
articular symptoms, and 2 chorea; so that nearly ninety per cent of this 
series of cases presented conclusive evidence of a rheumatic diathesis. 
Thirty per cent had chorea previously, or developed it while under ob- 
servation. The proportion of rheumatic cases corresponds very closely 
with C beadle's observations. In a series of 150 cases of valvular dis- 
ease, Still found distinct evidences of rheumatism in 142. 

Endocarditis may occur alone or with other manifestations of rheu- 
matism. While frequently associated with acute articular rheumatism, 
in a much larger number it is seen with articular symptoms which are 
so slight as to be overlooked entirely or passed over as unimportant. It 
may occur with or follow chorea, tonsillitis, or torticollis, with or without 
articular symptoms. The proportion of rheumatic cases in which endo- 
carditis occurs is much larger in children than in adults. In rare in- 
stances endocarditis is seen in the course of nearly all the infectious 
diseases, most frequently with scarlet fever, being often associated with 
pericarditis; but even in these conditions it is possible that it is some- 



) 



ENDOCARDITIS AND VALVULAR DISEASE. 583 

times rheumatic. The bacteriology of rheumatic endocarditis has not vet 
been determined with certainty. 

Lesions. — In the great majority of cases endocarditis affects the 
mitral valve, and often only this. In 150 autopsies upon children dying 
of cardiac disease, Povnton found the mitral valve involved in 149, but 
in 76 of these the changes were not marked ; in only i) was there marked 
mitral stenosis. The aortic valve was affected in 51, but in only !) was 
it seriously involved. Very striking was the frequency of pericarditis. 
Pericardia] adhesions were present in 113 cases, and in 77 the adhesions 
were complete, i. e., the pericardial cavity was obliterated. These find- 
ings agree substantially with the observations of other English author- 
ities, but in America the pericardial lesions are certainly not so prom- 
inent. 

The pathological changes of acute endocarditis do not differ essen- 
tially in early life from those seen in adults. There is first an accumula- 
tion of bacteria upon the endocardium of the valves. These produce 
necrosis, which is followed by a clot formation, consisting chiefly of blood 
platelets and fibrin, in the meshes of which are leucocytes and a few red 
cells. The next change is a growth of new connective tissue cells and 
blood-vessels, which may be slight and superficial, but the rheumatic 
lesion usually extends deeply with an extensive proliferation of connective 
tissue which after a time undergoes contraction. 

In the mildest forms of endocarditis it is possible for complete re- 
covery to take place. In other cases there is left only a slight valvular 
thickening, not enough to interfere in any important way with function. 
In most patients, however, more marked changes are left. The valvular 
segments are swollen, adherent, somewhat shortened and consequently 
insufficient. Other changes in the heart usually accompany acute endo- 
carditis. Dilatation is almost invariably present and is an important 
factor in producing insufficiency. In cases ending fatally there is very 
little hypertrophy; but if recovery occurs, hypertrophy develops and the 
lesion is compensated for in this way. A certain amount of myocarditis 
probably occurs in every severe case. It is most marked when pericar- 
ditis is also present. Emboli in children are rare. Subsequent attacks 
are exceedingly common and each one leaves the heart more seriously 
crippled. 

Chronic inflammation may follow the first attack or more often occur 
after repeated attacks. The changes resulting from chronic endocarditis 
are practically identical with those seen in adult life and need not be 
described here. Emphasis, however, should be laid upon the fact that \ 
the younger the child the more rapid the progress of the disease. 

Symptoms. — When endocarditis occurs as a primary disease, or when 
it is the only manifestation of rheumatism, it may begin abruptly with 
rather severe general symptoms — a temperature of 101° to 10 1° F., pros- 



584 DISEASES OF THE CIRCULATORY SYSTEM. 

tration, exaggerated heart action, restlessness, and sometimes dyspnoea, 
More frequently, however, it begins much loss acutely with only genera] 
malaise and slight fever, which often is not recognised without the ther- 
mometer. 1 1' the heart is not watched the diagnosis is not made and there 
may be no suspicion of the nature of the primary attack until some time 
afterward, when the existence of valvular disease is discovered. If, how- 
ever, the heart, is carefully and frequently examined there is heard, usu- 
ally on the third or fourth day of the illness, a soft, blowing, systolic 
murmur at the apex. 

Endocarditis occurring with rheumatism is by no means limited to 
those attacks with well-defined articular symptoms. It is very common 
and often severe when the articular symptoms are no more than stiffness, 
pain on motion, and Blight swelling of the feet or ankles. There is no 
relation between the severity of these symptoms and the seriousness of 
the cardiac lesion. Occurring during chorea or after tonsillitis there may 
be nothing to call attention to the heart except sometimes an increased 
rapidity or irregularity of the pulse and possibly increased prostration; 
but frequently the cardiac condition is not suspected until the heart is 
examined. 

Most of the cases of acute endocarditis seen in this country are of this 
mild type. Attacks of such severity as to produce death in the acute 
stage are relatively rare here, in marked contrast to the observations of 
English writers. 

The usual duration of acute endocarditis is from two to four weeks, 
the general symptoms slowly subsiding and, if the case progresses favour- 
ably, the cardiac symptoms improve, but there is usually left behind a 
g~ somewhat damaged heart because of valvular disease. In cases progress- 
> ' ing unfavourably a fatal termination may come in the course of from two 
to six weeks owing usually to one of three causes or a combination of 
these: (1) The rapid development of dilatation accompanied by the 
usual signs of cardiac insufficiency ; (2) pulmonary complications, gen- 
erally pneumonia; (3) the supervention of acute pericarditis. 

Course of Chronic Valvular Disease. — Chronic valvular disease fol- 
lows one or more attacks of acute endocarditis, and may exist for months 
and sometimes for years, before it is recognised. Its course is usually 
divided into two periods, the first being that while compensation is pres- 
ent, and the second after compensation has failed. The duration of the 
stage of compensation is indefinite. The only subjective symptom that 
is of much diagnostic value is shortness of breath on exertion. Occa- 
sionally other symptoms are present, such as praeeordial pain, attacks of 
palpitation, headache, epistaxis, anaemia, loss of weight, and cough. 
These are rarely constant, hut come on when the patient's general con- 
dition for any reason is below normal. As a rule, there is in young 
subjects a tendency to an increase in the disease, although this is often 



ENDOCARDITIS AND VALVULAB DISEASE 585 

slow, and may be interrupted by long periods in which the process ap 
pears to be stationary. At such times the patients either have do symp- 
toms, or suffer only from a slight amount of inconvenience on marked 

exertion. 

Failure in compensation is generally brought about by one of the 
following causes: The most frequent is an intercurrent attack of rheu- 
matism with a fresh endocarditis, which in a short time leads to a very 
greai increase in the heart's disability. It may be due to additional work 
thrown upon the heart from excessive muscular exertion, or to the strain 
of a prolonged attack of some acute illness, especially one that is liable 
to produce changes in the heart muscle, such as typhoid, diphtheria, or 
scarlei fever. It is sometimes the increased work which is thrown upon 
the heart especially at the time of puberty, owing to the rapid growth 
of the body. It may result from any cause which seriously affects the 
patient's general nutrition, particularly when this is associated with 
marked anaemia. 

The symptoms indicating failure of compensation are marked dysp- 
noea or orthopnoca and cough, sometimes accompanied by profuse ex- 
pectoration, which may be bloody, and in rare cases there may be larger 
pulmonary haemorrhages. With these may be associated other signs of 
pulmonary congestion and even pulmonary (edema. The obstruction to 
the systemic venous circulation leads to dropsy, which usually begins in 
the feet, sometimes in the face. There may be general anasarca and 
dropsy of the serous cavities, especially the peritonaeum and pleura; also 
enlargement and functional disturbances of the liver, enlargement of the 
spleen, dyspeptic symptoms, and chronic congestion of the kidney, with 
scanty urine and albuminuria. There may be dilatation of the superficial 
veins and cyanosis; and there may be cerebral symptoms, such as head- 
ache, dizziness, and fainting attacks. The pulse is small and soft, and 
the heart's action rapid and irregular; the cardiac sounds are feeble and 
often indistinguishable, and it may be impossible to decide what mur- 
murs, if any, are present. 

It is rare to see all the symptoms of chronic progressive cardiac fail- 
ure in children under ten years, but about the time of puberty they are 
common enough. The symptoms may increase in severity until death 
occurs, or they may be severe for a time and then nearly disappear, to 
return again after a longer or shorter interval. 1 Death may be i\wr to 
sudden cardiac paralysis, to intercurrent nephritis, pneumonia, embolism, 
inflammation of the serous membranes, or to (edema of the lungs. 

1 The course and termination of these cases of chronic valvular disease is well 
illustrated by the following history of a little girl who was under my observation for 
nine years: When first seen she was seven years old, and gave a history of cardiac 
symptoms for one year. There was then present a loud mitral regurgitant murmur, 
with considerable hypertrophy. There was general dropsy, and all the symptoms 



586 DISEASES OV THE CIRCULATORY SYSTEM. 

Physical Signs, — Mitral murmurs are altogether the most common 
both in acute and chronic disease. Of 141 cases of valvular disease, in 
children under fourteen years, observed clinically, mitral murmurs were 
present in 135; in 131 the murmur of mitral insufficiency was heard, and 
in 99 this alone. In mitral insufficiency there is regurgitation of blood 
from the left ventricle into the left auricle during systole. There is 
heard a systolic murmur, synchronous with the apex impulse and with 
the iirst sound of the heart, which may wholly or in part replace the first 
sound. It is loudest at the apex, transmitted to the left, and usually 
heard at the inferior angle of the left scapula. In acute endocarditis the 
murmur is at first very soft and usually increases in intensity for sev- 
eral days. It may be represented by the S3 r llables " whoo-ta " pronounced 
in a whisper. After attaining its maximum the murmur changes but 
little for some time. It may then diminish and eventually disappear 
entirely; but usually a murmur of moderate intensity remains. The 
only other important, sign of acute endocarditis is enlargement of the 
heart which is almost entirely from dilatation. If the acute inflammation 
supervenes upon an old lesion, the previous murmur becomes louder and 
harsher. In chronic endocarditis the murmur is similar to that of acute 
endocarditis but generally louder and more widely diffused, and may be 
audible all over the chest. It is accompanied by an accentuation of the 
pulmonic second sound and by signs of hypertrophy, especially of the 

pointed toward acute dilatation. Under treatment, the dropsy and other symptoms 
disappeared, and she went on comfortably for over a year. In her eighth and ninth 
years there were frequent attacks of subacute rheumatism, during which time the 
heart lesion steadily increased in severity. At twelve years there was an eruption of 
subcutaneous tendinous nodules, which remained for over two years. During this 
year there was heard for the first time a presystolic mitral murmur, accompanied by 
a very marked thrill, mitral stenosis having been gradually brought about by the 
slowly progressing endocarditis. This murmur gradually increased in intensity from 
that time, while the mitral regurgitant murmur became less distinct. The apex beat 
was then in the sixth space, two and a half inches to the left of the nipple. From 
the twelfth to the fifteenth year she grew very little in height or weight, and showed 
no signs of maturity, the cardiac symptoms being nearly stationary. In the fifteenth 
year she developed a marked enlargement of the liver and spleen with general dropsy 
and all the symptoms of cardiac insufficiency, these being the first symptoms of this 
character since she was seven years old. There was now heard for the first time an 
aortic regurgitant murmur in addition to the others formerly present. The symp- 
toms disappeared under treatment in the course of a few months, but six months later 
returned with greater severity and were accompanied by albuminuria, the patient 
dying from heart failure in a few weeks. During the last exacerbation there was 
heard a double aortic as well as a double mitral murmur. 

At autopsy the heart weighed fifteen ounces.,, There was a very great hyper- 
trophy, especially of the right ventricle, which was as thick as the left. All the cavi- 
ties were much dilated. The most important valvular lesion was mitral stenosis, the 
orifice not admitting the end of the little finger. The valves were the seat of cal- 
careous deposits. The curtains of the aortic valve were thickened and adherent; 
there was also thickening of the pulmonic and tricuspid valves. 



ENDOCARDITIS AND VALVULAB DISEASE. 587 

right heart. When both these signs arc wanting, the existi ace of mitral 
insufficiency is somewhal doubtful, as a similar murmur may be func- 
tional or accidental. In the early stages of the disease and during com- 
pensation, the Bigns of hypertrophy predominate; in the later stages or 
with broken compensation, those of dilatation. 

Mitral stenosis is relatively uncommon. It occurs after repeated at- 
tacks of rheumatism, with a slowly progressing endocarditis. It is usu- 
ally associated with mitral regurgitation. With this lesion there is ob- 
struction to the flow of blood from the left auricle into the left ventricle. 
It is mainly compensated for by hypertrophy of the right ventricle, but 
to a certain degree, also, by hypertrophy of the left auricle. The char- 
acteristic murmur of fully developed mitral stenosis is presystolic, pro- 
longed, rough in character, and terminates abruptly with a sharp first 
sound of the heart. It is loudest at or just above the apex, but is audible 
over only a circumscribed area. Quite as constant and important for 
diagnosis is the presence of a "purring thrill/' which is very distinct 
upon palpation, and terminates sharply as the apex strikes the chest 
wall. This murmur is not common in children and is heard only in 
cases in which cardiac disease has lasted several years. 

With milder grades of mitral stenosis, or earlier in the course of the 
disease, there may be heard, shortly after the second sound, a murmur 
softer in quality and of short duration. It is usually audible above and 
to the inner side of the apex beat. In point of time this is often spoken 
of as the early diastolic murmur of mitral stenosis. It may be repre- 
sented by the whispered syllables " whoo-ta-whoo/' in which the first syl- 
lable is the mitral systolic murmur, which is somewhat prolonged; the 
second syllable is the second cardiac sound; the last is the early diastolic 
murmur, which is much shorter than the systolic murmur. The pulse of 
mitral stenosis is usually small. 

Aortic lesions in children are much less common than mitral lesions, 
with which they are usually associated; they are seen in rather older 
patients. Aortic insufficiency is much more frequent than aortic 
stenosis. I have never seen it as the only lesion. It causes a regurgita- 
tion of blood from the aorta into the left ventricle during diastole. It 
is compensated for by dilatation and hypertrophy of the left ventricle. 
The signs of aortic insufficiency are a prolonged diastolic murmur, with 
or taking the place of the second sound of the heart, generally loudest 
at the left border of the sternum in the third space, and transmitted 
downward to the apex of the heart or the ensiform cartilage. This is 
invariably accompanied by signs of hypertrophy and dilatation of the 
left ventricle, which are usually marked. With great hypertrophy there 
is often bulging of the praecordium which may produce striking thoracic 
deformity. A characteristic symptom is the intense throbbing of the 
carotids, with the sudden distention followed by a complete collapse of 



;>ss DISEASES OF THE CIRCULATORY SYSTEM. 

their walls, and the " water-hammer " pulse of Corrigan. A capillary 
pulse is often seen. 

Aortic stenosis, unless congenital, is very rain 1 in early life, and almost 
never occurs as the only lesion. Aortic stenosis is compensated for by 
hypertrophy of the lefl ventricle. It causes a systolic murmur, which is 
usually loudest at the right border of the sternum in the second space, 
and is transmitted upward, being distinct in the carotids. The second 
sound is generally weak and may be replaced by a diastolic murmur. 
A systolic thrill over the aortic area is usually present. Without the 
signs of hypertrophy of the left ventricle, a positive diagnosis should 
not In 1 made. 

Tricuspid insufficiency is usually secondary to disease of the left side 
of the heart, occurring in its late stages. It most frequently follows 
mitral insufficiency, where it is usually due to dilatation of the right 
ventricle without changes in the valves. It may be secondary to certain 
diseases of the lungs, such as emphysema, chronic interstitial pneumonia, 
or chronic pleurisy, and it may be due to congenital malformation. Tri- 
cuspid insufficiency gives a systolic murmur, loudest over the lower part 
of the sternum, but heard usually over a small area. It is associated with 
signs of dilatation of the right ventricle. The jugular veins stand out 
prominently, and often show systolic pulsation, especially upon the right 
side. The symptoms associated with tricuspid regurgitation are due to 
general systemic venous obstruction. 

Tricuspid stenosis, pulmonic stenosis, and pulmo^ ic insufficiency are 
practically unknown in childhood except as congenital lesions. 

Prognosis. — The danger to life in acute endocarditis is not great un- 
less it is accompanied by pericarditis; but when both are present the 
outlook is serious. Of 115 fatal cases reported by Poynton, thirty-five 
proved fatal in the primary attack. It is difficult during the active stage 
to foretell how serious will be the resulting damage to the heart. It is 
only by watching the progress of a case that one can decide. As a rule 
the younger the child the worse the prognosis. 

Complete recovery from valvular disease is possible only when the 
lesions are very slight. Xot many children die from chronic cardiac 
disease before reaching the age of ten or twelve years. Up to about 
the time of puberty many children do very well; then they begin to lose 
ground, and may fail rapidly. But more often it is a fresh endocarditis 
accompanying an intercurrent attack of rheumatism which marks the be- 
ginning of a downward course. The proportion of children who have 
serious cardiac lesions before the age of eight years and reach adult 
life in good condition is very small. 

There are several features of cardiac disease in children, in conse- 
quence of which serious lesions tend to progress more rapidly than in 
adults. The muscular walls are less resistant, and hence dilatation oc- 



ENDOCARDITIS AM) VALVULAR DISEASE. 589 

curs much more readily than in adult life. The heart musl provide nol 
only for constant needs, hut for the growth of the body. It the patient's 
general nutrition is poor during the period of most rapid growth, this 
tells quickly and seriously upon the heart, and dilatation makes rapid 
progress. The demands made upon the heart at puberty are especially 
severe, by reason of the rapid growth of the body and the frequency of 
anaemia and malnutrition. There is always present the danger of rapid 
advances in the disease from intercurrent attacks of rheumatism, from 
which children are more likely to suffer than are older subjects. Ex- 
tensive pericardia] adhesions are frequent, and seriously handicap the 
heart, greatly increasing the tendency to dilatation. The effect upon the 
heart of poor food, unhygienic surroundings, and general malnutrition 
is much more marked than in adults. 

These unfavourable conditions are in part offset by others in which 
the child has an advantage over the adult. Disease of the coronary 
arteries is very rare, and the valvular lesion which is most frequently met 
with — mitral insufficiency — is that which admits of the most complete 
compensation. 

In making a prognosis in any given case, the amount of hypertrophy 
or dilatation which exists, and the presence or absence of pericardia] ad- 
hesions are more important than the location or the special character of 
the murmur. The presence of valvular disease in childhood increases 
the danger from every acute disease, especially pertussis, diphtheria, 
pneumonia, and scarlet fever. The chances of recurring attacks of rheu- 
matism must also be taken into account. 

Diagnosis. — Valvular disease is to be particularly distinguished from 
conditions in which there are heard functional or accidental murmurs. 
According to my own experience the latter are quite common even in 
young children. Mistakes usually arise from attaching too much impor- 
tance to the presence of murmurs, and too little to the changes in the 
walls and cavities of the heart, with which valvular disease is almost in- 
variably associated. It is not always possible to decide whether a murmur 
is organic or functional until the patient has been for some time under 
observation and treatment, particularly when anaemia is present. The 
diagnostic points, so far as the murmurs are concerned, are mentioned 
in connection with accidental murmurs. 

Treatment. — The first and altogether the most important indication 
for every case of recent endocarditis is to secure for the heart as complete 
rest as possible, not only during the period of active inflammation, hut 
for several succeeding weeks. The reason for this is that some dilatation 
is always present and this very readily increases. With children, proper 
rest can be secured only by keeping them in bed; and, when possible, 
in a recumbent position. The duration of the period of rest after mild 
attacks of endocarditis should be at least six weeks, and after severe 



590 DISEASES OV THE CIRCUIATORY SYSTEM. 

mi tacks, three months. In those young patients changes in the walls of 
the heart take place very rapidly and the gravest consequences are liable 
to follow a neglect i)\' these precautions. In old cases rest is indicated 
during every acute exacerbation; also whenever there is much dilatation 
and little hypertrophy, and whenever the signs of failing compensation 
are present. In these older cases rest is often impossible in the recumbent 
position; if seemed at all, it must be obtained with the child in the sit- 
ting posture or at least propped up with pillows. Whether much can be 
accomplished by the administration of anti-rheumatic remedies after en- 
docarditis has developed is very doubtful. Salicylates or aspirin and 
alkalies should, however, invariably be used with every fresh manifesta- 
tion of rheumatism, to prevent, if possible, an increase in the cardiac in- 
flammation. A child who is the subject of a chronic valvular disease 
should be constantly under a physician's observation. Irreparable harm 
often results from ignorant disregard of the simplest and most important 
rules of life for these patients. 

Several distinct conditions may be present which call for quite differ- 
ent management. The essential points may be stated in a few words: 
For all recent cases and during all exacerbations, rest, complete and pro- 
longed; for deformed valves with good heart walls and perfect compen- 
sation, fresh air, moderate exercise, and general tonics; for feeble heart 
walls, failing compensation and dilatation, rest and cardiac tonics. 

During the stage of compensation, treatment directed especially to 
the heart is rarely necessary. The main purpose should be to maintain 
the patient's general nutrition at the highest possible point during the 
period of active growth. At the very least the patient should be carefully 
examined three or four times each year, in order that the physician may 
note the progress of the disease, and be able to direct the child's educa- 
tion, occupation, exercise, and surroundings so as to meet, as far as 
possible, the changing conditions. To this end, diet, sleep, study, and 
exercise should receive the most careful attention. If malnutrition and 
anaemia are allowed to go on unchecked until they become severe, the 
cardiac disease may make rapid strides, and as much harm be done in a 
few months as otherwise might not occur in years. The question of ex- 
ercise and recreation is always a difficult one to settle. Often too little 
latitude is given, and the heart, like the voluntary muscles, loses its tone. 
Every form of exercise requiring a prolonged severe strain should be 
forbidden, particularly swimming and competitive games, like ball and 
tennis, and others requiring much running; but skating, rowing, horse- 
hack exercise, regulated gymnastics, and cycling on the level — all in 
moderation — may be allowed not only without harm, but with the great- 
est benefit; hut any of these, used immoderately, may be productive 
of great injury. All exercise should be taken with regularity and 
system, the amount being carefully measured by the child's condition, 



MALIGNANT ENDOCARDITIS. 591 

and increased freedom allowed only after watching the effect. If the 

patient is a boy who must earn his own living, the physician should see 
to it that the occupation chosen is not one likely to make special de- 
mands upon the heart or to expose him unduly to conditions likely to 
induce rheumatism; 

Special watchfulness is required at the time of puberty to prevenl 
overpressure in schools, and the development of anaemia. The first symp- 
toms of these conditions should be treated energetically, and if the heart 
seems to be overtaxed the child should be put to bed. Those who are 
specially liable to rheumatic attacks should, if possible, spend the winter 
and spring months in a warm, dry climate. 

In the stage of failing compensation, the same general conditions are 
present as in adults, and they are to be managed in pretty much the same 
way. When such symptoms are first seen, prolonged rest in bed should 
be insisted upon as the thing most likely to restore the normal conditions. 
Digitalis and strophanthus are useful in children with about the same 
indications as in adults, viz., marked dilatation, dropsy, low arterial 
tension, and weak pulse. They may be used in doses of from five to ten 
drops of the tincture every four to six hours for a child of ten years. 
If there is much dilatation of the right side of the heart the same treat- 
ment is indicated as described in pericarditis. One should be cautious 
about using digitalis for an irregular and overacting heart, opium being 
decidedly preferable under these conditions. An overloaded venous cir- 
culation may be relieved by diuretics, by saline purgatives, or even by 
venesection. Iron and tonics generally are indicated, particularly strych- 
nine and cod-liver oil. 

MALIGNANT ENDOCARDITIS. 

Malignant or ulcerative endocarditis is rare in childhood. The 
youngest cases I have found reported are one by Bond in an infant of 
two and a half months, and one by Harris in a boy four years old. In 
Bond's case the mitral valve was affected. It was due to the bacillus 
pyocyaneus. In Harris' case the right side of the heart was affected 
and the lesion was secondary to a congenital malformation. Of the 
cases reported in early life, most have been in children over ten years of 
age. Malignant endocarditis is rarely if ever primary. It may be seen 
in any infectious disease or septic process. In seventy-five per cent of 
the cases it is ingrafted upon a previous valvular disease. In my series 
of collected cases of congenital malformations of the heart, there were 
four deaths from malignant endocarditis, all but one, however, occurring 
in adult life. The bacteria most frequently concerned are the staphy- 
lococcus or streptococcus, next the pneumococcus, and rarely the gono- 
coccus, the influenza or the pyocyaneus bacillus. 

Malignant endocarditis presents a great variety of symptoms, often 



592 DISEASES OF THE CIRCULATOR? SYSTEM. 

making the diagnosis extremely difficult. There is generally a remittent 
type of fever, sometimes repeated rigors, sweating, low delirium, stupor 
or coma, and extreme prostration. There is often a fine petechial erup- 
tion. Usually there is a cardiac nun-nun-, the location of which depends 
upon the seat of the disease; it is most frequently the murmur of mitral 
regurgitation. It is sometimes faint, and may be absent. From the 
emboli there may result hemiplegia, rapid swelling of the spleen, bloody 
urine or pneumonia. The disease lasts from three weeks to three months, 
death being the almost invariable termination. The most characteristic 
features of malignant endocarditis are the development of pyaemic or 
typhoid symptoms with a petechial eruption, in a patient who has pre- 
viously had valvular disease. Blood cultures in most cases give positive 
results, though not always early in the disease. 

The treatment is symptomatic. The use of vaccines has not met 
expectations; in the most acute eases no benefit has generally followed 
their administration, although in the more prolonged types they seem 
at times to have been of value. 



MYOCARDITIS. 

Disease of the muscular wall of the heart is rare in children, and of 
comparatively little importance, except in connection with acute endo- 
and pericarditis and the acute infectious diseases. It is almost invariably 
secondary to some infectious process. Aside from the rheumatic condi- 
tions already considered the diseases which furnish most of the cases 
are searlet fever, diphtheria, and influenza. The most important local 
cause is pericarditis with adhesions. 

Lesions. — In extra-uterine life, myocarditis as a rule affects chiefly 
the wall of the left ventricle, the papillary muscles, or the septum, but 
the entire organ is involved. The heart is of a grayish or yellowish-red 
colour, very soft, friable, and flabby, and there is frequently dilatation of 
the cavities. 

Two varieties of myocarditis are described. In the parenchymatous 
form there is a degeneration of the muscle fibre which, according to 
Romberg, is most frequently albuminous, next fatty, and least frequently 
hyaline. There is a loss of the transverse striations, and there may be 
complete disintegration of the fibres. This process may be circumscribed, 
but it is usually diffuse. In the interstitial form the lesion usually occurs 
in small, circumscribed areas. There is an infiltration of round cells, 
chiefly mononuclear, between the muscular fibres of the heart. The proc- 
ess, when acute, may result in absorption or in the production of small 
sses. In chronic cases it may lead to the formation of areas of dense 
connective tissue resembling cicatrices, in the heart wall. Either the 
interstitial or the parenchymatous form may occur alone, but in most 



ACCIDENTAL Ml i:\Il l:s 593 

of the acute cases they are combined. In addition, (here is usually Borne 
degree of mural endocarditis and inflammation of the pericardium oext 

to the heart wall. Dilatation frequently follows. Cardiac aneurism and 
even rupture have been known to occur in a child of six years (Hadden's 
case). 

Symptoms. — In many cases in which advanced lesions have been 
found at autopsy there have been no symptoms appreciated during life. 
Careful examination of the heart, however, will usually show an altera- 
tion in the first cardiac sound, the muscular quality diminishing and 
the valvular quality increasing. This may go on even to a total disap- 
pearance of the muscular quality and only a flapping valvular sound may 
remain. The first and the second sounds are then almost alike. In such 
severe cases diastole is relatively short and the rhythm is much like that 
of fcetal life. A systolic murmur due to dilatation of the auriculo-ven- 
tricular ring, or to imperfect action of the papillary muscles, may be 
heard at the apex. The heart is usually slightly dilated, but may be 
excessively so. Its action is generally increased in rapidity and may be 
irregular; a slow heart, 50 to 70, with feeble, valvular sounds is less 
frequent but very characteristic. The apex beat is diminished in intensity 
and the pulse is soft and weak. The blood pressure is low, frequently 
60 mm. or even less. Other symptoms may be present that are dependent 
upon feeble heart action — pallor, dyspnoea, slight cyanosis, and attacks 
of syncope. Less frequently there may be dropsy of the feet or the serous 
cavities, and scanty urine, sometimes containing albumin. Death may 
occur suddenly from cardiac paralysis or gradually from circulatory fail- 
ure. Eecovery may take place after alarming symptoms have been 
present, these slowly abating. It may be many weeks before the normal 
cardiac sounds are heard. 

Treatment. — This is mainly symptomatic. After severe attacks of 
those infectious diseases in which myocarditis is liable to occur, and at 
any time when it is suspected, patients should be kept recumbent for 
several weeks, and special care exercised to prevent any sudden exertion, 
as death has resulted from so slight a thing as suddenly sitting up in 
bed. Once definite symptoms have developed, absolute rest is imperative. 
Much more is to be expected from complete rest than from drugs, which 
as often employed may do positive harm. Digitalis should be used with 
Cc.ution, and never in large doses. In some cases with symptoms indicat- 
ing imminent heart failure rather striking benefit has followed the use 
of morphine hypodermically. 



ACCIDENTAL MURMURS. 

In a paragraph upon the diagnosis of congenital cardiac disease, 
reference has already been made to a type of murmur frequently beard 
39 



594 DISEASES OF THE CIRCULATORY SYSTEM. 

in children and which may be confounded with a murmur due to organic 
disease. 

Accidental murmurs may also be heard in cases of marked anaemia. 
These are not rare even in infancy. They may be eon Founded with 
organic murmurs either from congenita] malformations or from acquired 
disease. In any anaemic infant, as well as older child, one should hesitate 
to make a diagnosis either of congenital or acquired organic disease, from 
the mere presence of a murmur. 

An anaemic murmur is usually systolic, generally but not always loud- 
est at the base of the heart, audible in the carotids, often in the sub- 
clavian, and occasionally over any large artery. The murmur varies 
from day to day, and sometimes it is altered by changing the position of 
the patient. It may be loud enough to be heard over a great part of the 
chest in front, and even behind. There is frequently present a venous 
hum in the neck. There are no signs of hypertrophy, nor is there the 
accentuated second sound so characteristic of mitral disease. The pulse 
is not usually strong. Anaemic murmurs diminish in intensity and ulti- 
mately disappear with improvement in the general condition of the 
patient 

FUNCTIONAL DISORDERS OF THE HEART. 

Disturbances in the heart's action unconnected with organic disease, 
are not very common in young children; but after the seventh year they 
increase in frequency up to the time of puberty. One of the most im- 
portant causes is indigestion; another is overpressure in schools, or any- 
thing else leading to nervous exhaustion. In these circumstances it is 
usually associated with other mental or psychical disturbances. An im- 
portant predisposing cause is the demand made upon the heart by the 
rapid growth of the body about the time of puberty, particularly when 
this is associated with anaemia. In some of the cases there is a definite 
exciting cause, such as fright or great excitement, and it may be due to 
the excessive use of tea, coffee, or tobacco, especially in the form of 
cigarette-smoking. In a few instances it has been traced to masturbation. 
It may follow any acute disease, such as t/yphoid fever, malaria, or one 
of the exanthemata, and occasionally it occurs in the course of these dis- 
eases, or with bronchitis or pneumonia. 

Symptoms. — The usual manifestations are attacks of palpitation; less 
frequently there is tachycardia or bradycardia. The majority of chil- 
dren complain more with functional disturbances than with organic dis- 
ease, certainly while the latter is accompanied by compensation. Attacks 
of palpitation occur in paroxysms. In the severe form there is usually 
a sense of oppression in the region of the heart, with some dyspnoea, or 
even orthopncea. The pulse is usually rapid, from 120 to 130, and is 
irregular both as to force and rhythm. The carotids pulsate strongly. 



DISEASES OF THE BLOOD VESSELS ;,!>;, 

The apex Impulse is fell over an increased area, the heari sounds are 
usually strong but irregular, and sometimes a Blighl murmur is heard. 
The face is pale or flushed. There may be headache, vertigo, spots before 
the eyes, and noises in the ears. Sometimes there is slight cyanosis with 
cold hands and feet, and genera] perspiration. The frequency of these 
attacks depends upon the nature of the exciting cause. Their duration 
is from a tV\v minutes to several hours. 

Diagnosis. — Functional disorders are differentiated from organic car- 
diac disease only by careful and repeated examinations of the heart. In 
the diagnosis of functional disturbance especial importance is to be at- 
tached to a neurotic or neurasthenic condition of the patient, to the 
presence of some adequate exciting cause, the absence of evidence of 
enlargement of the heart, and the fact that the pulmonic second sound 
is not increased. 

Prognosis. — This in most cases is favourable, for with the removal 
of the cause, with improvement in the patient's general condition, with 
the growth of the body, and in girls with the establishment of menstrua- 
tion, the attacks usually disappear. 

Treatment. — The curative treatment is to be directed toward the 
cause. When no special cause can be discovered a general tonic plan of 
treatment should be adopted, with careful regulation of the patient's diet, 
exercise, and mode of life. All stimulating food, tea, coffee, and tobacco 
should be prohibited. Anaemia should receive its appropriate remedies. 
The hours of sleep and study, and the amount and character of exercise 
allowed, should be carefully regulated. Between attacks no treatment 
of the heart is necessary. During attacks bromides or valerian may be 
useful. 

DISEASES OF THE BLOOD-VESSELS. 

Abnormally Small Arteries (Arterial hypoplasia). — This condition 
is not a very common one, but it has attracted a good deal of attention, 
having been studied especially by Virchow. The only thing which is 
abnormal in the circulatory system may be that the aorta, and sometimes 
all the large vessels are only two-thirds or three-fourths their usual 
calibre, or even less. This may interfere seriously with the growth and 
development of the body, especially of the genital organs, although this 
result is not a constant one. The condition is found occasionally in cases 
of chlorosis, and in the congenital cases it may be the chief cause. There 
is sometimes associated a certain amount of hypertrophy of the heart. 
The other symptoms are anaemia, and sometimes an imperfect develop- 
ment of the body. A positive diagnosis during life is impossible. 

Aneurism and Atheroma. — In early life chronic disease of the blood- 
vessels is exceedingly rare, yet a sufficient number of observations have 
been recorded to show that even young children are not exempt from this 



596 DISEASES OF THE CIRCULATORY SYSTEM. 

form o( disease. Sanne ■ records the youngest case, which occurred in a 
foetus born at about the eighth month, in whose body there was found a 
large aneurism o\' the abdominal aorta just below the origin of the 
renal arteries. Le Boutillier 2 has collected seven cases of thoracic aneu- 
rism in children under ten years; the arch of the aorta was the usual 
seat. 

Probably the most important etiological factor, as in adult life, is 
syphilis, but in only a few of the cases reported was the evidence of 
syphilis conclusive. In two cases there was general tuberculosis. In at 
least two cases whooping-cough appeared to act as a contributing cause. 
Aneurism may also be due to some local condition, such as an erosion 
from a bony growth, an abscess in the neighbourhood, or to embolism. 
The symptoms and course of aneurism in young children do not differ 
essentially from those of the disease as seen in adults. 

In addition to the cases of aneurism referred to above, I have found 
reports of seven cases of atheroma in very young subjects. In Sanne's 
case the patient w r as but two years old, and patches of atheromatous de- 
generation were found in several places in the aorta. In Hawkins* case, 
eleven years old, there was found extensive atheromatous disease of the 
aorta, subclavian and carotid arteries. In Filatoff's case, atheromatous 
degeneration affected the arteries at the base of the brain, causing death 
from cerebral haemorrhage. It is interesting to note that in this patient, 
who was only eleven years old, there was also present chronic diffuse 
nephritis with contracted kidneys. A similar condition of the kidneys 
and arteries was observed by Dickinson in a girl of six years. 

Embolism and Thrombosis. — Embolism is very rare in early life, even 
with acute endocarditis. The emboli are usually swept into the circu- 
lation from vegetations upon the valves of the heart. The symptoms 
which they produce will depend upon the nature of the emboli and the 
vessels occluded by them. If they lodge in the brain they may cause 
paralysis or convulsions; if in the spleen, pain and swelling of this 
organ; if in the kidneys, pain, tenderness, and sometimes haematuria; 
if in the lungs, cough, sometimes accompanied by haemoptysis and occa- 
sionally by a sharp thoracic pain. If the emboli are infectious, they 
may give rise to abscesses. The pathological results following em- 
bolism are similar to those which are seen in adults. 

The most frequent form of thrombosis, that occurring in the sinuses 
of the brain, is discussed in connection with Diseases of the Xervous 
System. Cardiac thrombi, especially of the right side of the heart, are 
not infrequently found in patients dying from heart disease, pneu- 
monia, and occasionally also from other acute inflammatory processes 

1 Sann6, Revue Mcnsuelle des Maladies des 1'Enfance, vol. v, p. 56. 

2 American Journal of the Medical Sciences, May, 1906. In these articles will be 
found references to most of the reported cases. 



DISEASES OF THE BLOOD-VESSELS 597 

and acute infectious diseases, particularly diphtheria. These thrombi 
arc in most eases produced during the last few hours of life, or jusi at 
the time of death, and arc of do clinical importance. They frequently 
extend from the heart into the large blood-vessels, particularly the pul- 
monary artery. Thrombosis occasionally occurs in all the large vascular 
trunks in childhood as well as in adult life. 

Thrombosis of the Internal Jugular Vein. — Pasteur ' reports a 
in a child two and a half years old, in which the middle of the vein was 
filled with an organised thrombus, and the lower portion obliterated and 
reduced to a fibrous cord. The symptoms were swelling, (edema, and 
cyanosis of the face, and dilatation of the facial vein, hut not of the ex- 
ternal jugular. There were clubbing of the fingers and oedema of the 
feet, but not of the arm. The heart was found to he dilated and hyper- 
trophied, hut was not the seat of valvular disease. The symptoms 
had existed since an attack of pneumonia, eighteen months before 
death. 

Thrombosis of the Vena Cava. — Quite a numher of cases are on rec- 
ord where this has occurred as the result of pressure from large abdom- 
inal tumours; it has followed new growths of the kidney and large 
masses of tuherculous lymph nodes. Neurutter and Salmon have recorded 
a case of thrombosis, apparently of marantic origin, in a child seven 
years old. The thrombus filled the vena cava, and extended to the 
origin of the hepatic veins and into both femorals. Death occurred from 
tuberculosis. In Scudder's case (seventeen years old) there was appar- 
ently obliteration (probably congenital) of the inferior vena cava; there 
was an extensive varicose condition of all the abdominal veins. The 
symptoms of thrombosis of the vena cava are swelling and oedema of the 
feet — sometimes of the abdominal walls and the groin — and very great 
dilatation of the superficial abdominal veins. 

Thrombosis of the Aorta. — A case has been reported by Leopold in 
a newly-born child which was delivered by version. The thrombus was 
of recent origin, and filled the lower aorta, extending into the femoral 
artery. A case of thrombosis of the aorta occurring in a girl of thir- 
teen years has been reported by Wallis. The aorta was very narrow, and 
probably the seat of syphilitic disease. The thrombus extended from the 
origin f the renal arteries to the cceliac axis. 

Thrombosis in Infectious Diseases. — There is occasionally seen in 
typhoid fever, but more frequently in diphtheria, thrombosis of some of 
the large venous trunks, usually of one of the lower extremities. The 
symptoms are pain, localised swelling, and partial paralysis. If the 
artery is affected, there may be gangrene. 

1 Lancet, February 11, 1SS8. 



SECTION VI. 
DISEASES OF THE URO-GENITAL SYSTEM. 

CHAPTER I. 
THE URINE IN INFANCY AND CHILDHOOD. 

While a study of the urine is of much less importance in early life 
than of the symptoms referable either to the digestive or respiratory 
system, it is deserving of much more attention than it has generally re- 
ceived. In infancy especially it is attended with some difficulty, owing 
to the fact that it is by no means an easy matter to secure readily speci- 
mens for examination. 

Methods of Collecting Urine. — In male infants this may be done by 
placing the penis in the neck of a small bottle, which lies between the 
thighs, and is secured in position by pieces of tape passing over the hips 
and beneath the perinaeum. The urine of female infants can sometimes 
be collected in a similar way by placing a small cup or a large-mouthed 
bottle over the vulva and holding it in place by the napkin or by pieces 
of adhesive plaster. A plan often successful is to put the infant upon a 
chamber after a long sleep. It should be done at the instant of waking 
or the child may be wakened for the purpose. A cold hand over the 
bladder facilitates matters. A small amount, sufficient to test for albu- 
min, may often be obtained by placing absorbent cotton over the vulva 
or penis. The most certain of all means, however, is catheterisation, 
which, however, should not be resorted to unless absolutely necessary. 
A soft-rubber catheter, size 6 or 7, American scale (9 or 11 French), 
should be used for infants. 

Daily Quantity. — This is relatively much larger in infants than in 
older children and in adults, on account of the large amount of water 
taken with the food. The quantity fluctuates widely from day to day, 
according to the amount of fluid food taken and the activity of the skin 
and bowels. The figures on the opposite page are the averages obtained 
by combining the results of the investigations of Schabanowa, Cruse, 
Camerer, Pollak, Martin-Ruge, Berti, Schirr, and Herter. 

Frequency of Micturition. — This is greatest in young infants, and 
diminishes steadily as age advances. In infancy, during the waking 
hours, the urine is passed very frequently, often two or three times an 
598 



THE URINE IN INFANCY AND CHILDHOOD. 599 

Average Daily Quantity of Urine in Health. 



Age. 



First twenty-four hours . . 
Second twenty-four hours . 

Three to six days 

Seven days to two months 

Two to six months 

Six months to two j^ears . . 

Two to five years 

Five to eight years 

Eight to fourteen years . . . 




< lunees. 



to 
1 



3 
5 

7 

8 

16 

20 

32 



hour, while during sleep it is retained from two to six hours. By the 
third year the urine may be held during sleep for eight or nine hours, 
and at other times for two or three hours. Such control of the sphinc- 
ter of the bladder is often obtained at two years, and sometimes even at 
an earlier period. From slight nervous disturbances or minor ailments 
of any kind, this control is impaired, and the water may be passed by 
children of four or five years with the frequency seen in infants. 

Physical Character and Composition. — The urine of the newly born 
is usually highly coloured. During later infancy it is pale and fre- 
quently turbid, even when practically normal, owing to the presence of 
mucus; this turbidity often no amount of filtration will entirely remove. 
Less frequently, turbidity depends upon urates. The urine of the first 
few days of life often shows a deposit of urates or uric acid in the form 
of a pink or reddish-yellow stain upon the napkin. The reaction of the 
urine at this time is usually strongly acid, but throughout the rest of 
infancy it is faintly acid or neutral. 

The specific gravity is higher during the first two days than at any 
time in infancy on account of the scanty supply of fluid taken; it is 
usually lowest from the third to the sixth day, but. from this time it rises 
steadily until puberty is reached. The specific gravity varies with the 
quantity. From the writers already referred to, the following figures 
are taken : 

Specific gravity. 

First to third day 1 .010 to 1 .012 

Fourth to tenth day 1 .004 " 1 00S 

Tenth day to sixth month 1 .004 " 1 .010 

Six months to two years 1 . 00(3 " 1.012 

Two to eight years 1 . 008 " 1.016 

Eight to fourteen years 1.012 " 1 020 

Microscopically, the urine of the newly born shows the presence of 
many squamous epithelial cells, mucus, granular mailer, and crystals of 
uric acid and amorphous or crystalline urates. It is not uncommon to 



(UK) DISEASES OF THE URO GENITAL SYSTEM. 

find hyaline and even granular casts. Mart in- Huge found hyaline casts 
in the urine of fourteen out o\' twenty-four healthy nursing infants ex- 
amined during the first week. Granular casts were much less frequent. 
The microscopical appearances of the normal urine of later infancy and 
childhood present no peculiarities. 

The inorganic salts (phosphates, chlorides, sulphates) are all present 
in the urine of the newly horn, hut in relatively small quantities, in- 
creasing as age advances. The colouring matters are also less abundant. 

Albumin is often present in the urine during the first days, hut 
usually in small amount. Cruse found it twenty-eight times in ninety 
observations upon healthy infants; usually the quantity was small, 
amounting to traces only, hut in two cases it was quite large upon the 
second day. These observations are confirmed by the investigations of 
Martin-Ruge, and also of Pollak. 

Sugar is frequently found in the urine of healthy infants during the 
first two months. It may be made to appear in the urine of healthy 
infants by simply increasing the quantity ingested. The different sugars 
vary as regards the amount which can be taken before it is thus elim- 
inated. According to Grosz, lactose appears if the quantity is increased 
to three or four grammes per kilo, of body weight; glucose, only when 
five grammes, and maltose, not until seven and seven-tenths grammes 
per kilo, are given. 

CYCLIC OR ORTHOSTATIC ALBUMINURIA. 

Etiology. — This condition, although a rare one in young children, is 
occasionally seen between the ages of ten and sixteen years. I shall not 
in this connection include eases sometimes classed as febrile albu- 
minuria, in which there is usually present the condition described as 
acute degeneration of the kidneys. 

The causes of orthostatic albuminuria, and the circumstances in 
which it has been observed, are many and varied. It is much more 
common in males than in females. In certain cases albuminuria is 
distinctly traceable to cold bathing; in others, to fatigue following ex- 
cessive muscular exercise ; in still others, to dyspeptic conditions. It 
may be associated with a diet rich in nitrogenous food. Sometimes none 
of these conditions exist, and there is simply the occasional presence of 
albumin in the urine. 

The theory which most satisfactorily explains this condition is that 
the most important factor is a mechanical one — that the albuminuria is 
due to the upright position. The vascular pressure in the kidney may 
he increased by deformities of the spine. 

Symptoms. — Many of the patients exhibiting cyclic or periodic al- 
buminuria are well nourished, and have no other signs of disease; others 
show dyspeptic symptoms, and are anaamic and poorly nourished, surfer- 



HEMATURIA. 601 

ing from headaches and other neuroses. The amounl of albumin is 
commonly small. Jn many patients albuminuria ie regularly cyclic in 
character, albumin being absenl in the urine passed during the oigW 
or early morning, hut present during the day. In a case reported by 
Tiemann, the morning urine showed no trace of albumin in Beventy- 
eighl of eighty-four examinations. At neon albumin was present in 
ninety-eight of one hundred and thirteen examinations. It is not in- 
frequently associated with temporary glycosuria. As a rule, casts are 
absent, although it is not uncommon to find a few hyaline casts, and 
occasionally granular casts are also present. Bui dropsy, cardiac hyper- 
trophy, a pulse of high tension, retinal changes, and the characteristic 
symptoms of nephritis are absent. 

Too much stress is certainly laid by Pavy and many other writers 
upon the fact that the albumin is found in the urine only at certain 
times in the day. This is not peculiar to functional albuminuria, as the 
same thing occurs in many cases of chronic nephritis, especially in the 
early stages, when the amount of albumin present is small. All these 
cases must be carefully watched for a long time and many observations 
made, before nephritis can positively be excluded. 

Prognosis. — The prognosis in purely functional albuminuria is good. 
But many patients who for a considerable time w^ere thought to have 
only functional albuminuria have ultimately developed nephritis. A 
favourable prognosis is therefore possible only after long observation. 

Treatment. — This is to be directed toward the patient's general con- 
dition. Dyspeptic symptoms must be relieved, the patient's mode of life 
regulated, only moderate exercise allowed, and a simple diet given. If 
the urine is of high specific gravity, and contains oxalate of lime crys- 
tals, alkalies and mineral waters should be given in addition. Iron is 
indicated if there is anaemia. 



HEMATURIA. 

Hematuria is characterised by the presence of red blood-cells in the 
urine, and is to he distinguished from hemoglobinuria where only blood 
pigment is present. 

Hematuria may result from local or general causes. In infancy it 
may be due to new growths of the kidney. Such haemorrhages, though 
rare, may be abundant, and may be seen early. 1 hematuria may occur 
also as a symptom of acute nephritis, especially that complicating scarlet 
fever, or it may result from the irritation of a calculus in the kidney, the 
ureter, or the bladder. In rare instances its cause is a new growth of 
the bladder, and it may he due to traumatism. It may sometime- he 
produced by the irritation of a highly concentrated urine, owing to the 
fact that too little fluid is taken. I saw a marked example of this in an 



602 DISEASES OF THE ORO GENITAL SYSTEM. 

infant eight months old, where ao other explanation could be found. 
1 once saw hematuria following uric-acid infarctions in the newly born. 
It may also occur at this time as one of the symptoms of sepsis. Among 
the genera] causes the most important are: the haemorrhagiC disease 
of the newly born; the blood dyscrasiae, such as scurvy, purpura, and 
haemophilia; and infectious diseases, particularly typhoid, scarlet fever, 
influenza, and malaria. In most, of these eases the amount of blood 
passed is small. When it is large it may appear in the urine as clear 
blood, or as clots, or it may impart simply a reddish or smoky colour 
to the urine. The colour, however, is not so reliable as a microscopical 
examination. 

Large haemorrhages are much more likely to come from the kidneys 
than from the bladder. The presence of blood casts from the renal 
tubules, or larger ones from the ureter, are conclusive evidence of the 
renal origin of the haemorrhage. 

The treatment of haematuria should be directed to the cause upon 
which it depends. In infancy scurvy especially should not be overlooked. 

HEMOGLOBINURIA. 

In this condition blood pigment appears in the urine in large quan- 
tity, but red blood-cells are very few in number, or are absent altogether. 
In severe cases the urine may be almost black. There is commonly a 
small amount of albumin. This condition may be recognised by the ap- 
pearance of granules of pigment under the microscope, or by Heller's test ; 
the most conclusive means of diagnosis, however, is by the spectroscope. 

Epidemic haemoglobinuria (Winckel's disease) has already been de- 
scribed in the chapter on Diseases of the Xewly Born. Haemoglobinuria 
may be due to certain poisons, as carbolic acid or chlorate of potash, or 
to certain infectious diseases, as scarlet fever, typhoid fever, malaria, 
syphilis, or erysipelas. 

Paroxysmal haemoglobinuria occurs in childhood, although it is an 
exceedingly rare condition. A typical case in a child of four and a half, 
years has been reported by Mackenzie. This was a delicate child of 
syphilitic parents; the hamioglobinuria was preceded by fever and chills, 
without any other evidence of the presence of malaria. In certain chil- 
dren it follows exposure to cold or chilling of the surface of the body. 
The treatment of this condition is very unsatisfactory, but susceptible 
individuals should reside in a warm climate. For further description 
text-books on general medicine should be consulted. 

PYURIA. 

Pus in the urine may exist as an acute or a chronic condition. In 
either case, in a child, it is much more Likely to come from the pelvis of 



INDICANURIA. 603 

the kidney than from any other source. II may, however, come from 
any part of the genito-urinary tract — the kidney or its pelvis, the ureters, 
the bladder, the urethra, or the vagina. Sometimes it conies from an 

outside source, as when an abscess from perinephritis, appendicitis, or 
canes of the spine opens into the urinary tract. 

Coming from the pelvis of the kidney, pus may indicate, if the con- 
dition is an acute one, pyelitis, pyelo-nephritis, Or pyonephrosis; if it is 
chronic, it points to renal tuberculosis or calculus. The amount of pua 
in any of these conditions may he quite Large. The urine is turbid ami 
usually acid in reaction. It contains many epithelial cells of the tran- 
sitional variety. A urine containing much pus is always albuminous. 
It is rare that pus comes from the ureters except in connection with 
congenital malformations or the impaction of calculi. Pus from the 
bladder is not usually in large quantity, and may he mixed with mucus. 
The urine may be alkaline or acid in reaction; there may he associated 
the symptoms of vesical irritation or of cystitis. Pus from the lower 
genital tract is rare in children, and its causes may often be recognised 
by a local examination. When the cause of pyuria is the opening of 
an abscess into the urinary tract there is generally a sudden appear- 
ance of pus in large amount. The pyuria is usually in such cases of 
short duration, possibly only a few days, and it may disappear quite 
rapidly. 

The nature of the infection can be determined only by cultures made 
from a catheterised specimen. This information is of considerable aid 
both in diagnosis and prognosis. 

The treatment of pyuria depends altogether upon its cause. Im- 
provement in the symptoms sometimes follows the use of hexamethyl- 
enamine (urotropin), which may be given in doses of from two to five 
grains three times a day to a child of five years. 

INDICANURIA. 

Indicanuria is a condition characterised by the presence of indican 
in the urine. Indican (indoxyl-potassium sulphate) is derived from 
indol, which is formed in the intestine by the agency of bacteria from 
the excessive putrefaction of protein. It may also be produced in other 
parts of the body where putrefactive processes are going on, as in ex- 
tensive suppuration without drainage, in pulmonary cavities, empyema, 
etc. Indican is only one of the ethereal sulphates produced in the man- 
ner above indicated, and when other conditions like those mentioned are 
excluded it may be taken as an index of the amount of putrefaction 
going on in the intestine. 

Indicanuria is most frequently a symptom either of acute or chronic 
intestinal disease. It is important as being a guide by which we may 



604 DISEASES OF THE URO-GENITAL SYSTEM. 

estimate the other symptoms in these conditions, and the effects of 
treatment. While a trace of indiean is frequently present in health, a 
strong indiean reaction is always to he considered abnormal in a child. 
The indications are to diminish intestinal putrefaction. The treat- 
ment is mainly dietetic, [ndicanuria is usually increased by a meat diet 
and diminished by a milk diet. Other measures are referred to in the 
treatment o( chronic intestinal indigestion. 



ACETONURIA— DIACETONURIA, ETC. 

Acetone exists in small quantities in the urine of healthy children. 
It is also found in large quantities in many febrile diseases. Acetone, 
diacetic, and /J-oxybutyric acids are products formed in the incomplete 
metabolism of fat. Xormal combustion of fat can not take place unless 
there is at the same time combustion of carbohydrates. The substances 
mentioned are therefore found in the urine whenever an insufficient 
amount of carbohydrate is ingested, or when the amount ingested can 
not be utilised. In acute diseases these substances are present for the 
first reason mentioned; in diabetes, for the second reason. There is no 
connection between acetonuria and the nervous symptoms accompany- 
ing fever. 

Acetone, diacetic, and /?-oxybutyric acids are regularly found in the 
urine of patients suffering from cyclic vomiting; they are probably a 
result, not the cause, of the attacks. In progressing cases of diabetes 
and in diabetic coma these substances are present in large amount. 

ANURIA. 

By this term is meant an arrest of the urinary secretion. To that 
form which occurs in the course of renal disease the term " suppres- 
sion " is generally applied. Anuria is to be carefully distinguished 
from retention, from the scanty secretion which occurs whenever food is 
refused or withheld on account of illness, and also from that which ac- 
companies acute diarrhoea, with large, watery discharges. Anuria is 
sometimes seen in the newly born, where it depends upon some mal- 
formation of the genital tract; or, more frequently, upon uric-acid in- 
farctions in the kidneys. The first urine passed after such an attack 
is very often highly acid, and may contain an abundance of uric-acid 
crystals and larger masses visible to the naked eye. Other cases admit 
of no such explanation. For the time, the secretion appears to be com- 
pletely arrested, as the bladder, both by palpation and catheterisation, 
is found to be empty. This condition is uncommon in infancy, but it 
may continue for from twelve to thirty-six hours. So long as infants 
appear to be perfectly normal in every other respect, the suspension 



DIABETES INSIPIDUS (POLYURIA). 605 

of the urinary secretion even for twenty-four hours Deed excite no 
anxiety. 

The treatment consists in the administration of sweet Bpiritfl of 
nitre, in combination with the acetate or citrate of potash, and plenty 
of water. To a newly-born infant one minim of the nil re and one grain 
of the citrate of potash may be given every hour or two, in water, until 
the urinary secretion is established, which will usually he in six or 
eight hours. If the urine is very highly acid, and stains the napkins, 
the potash should be continued for several days. Jlot fomentations over 
the kidneys may be used. 



DIABETES INSIPIDUS (POLYURIA). 

This is a chronic disease characterised by the excretion of a very 
large amount of pale urine of low specific gravity. It is invariably ac- 
companied by polydipsia. The disease is an exceedingly rare one in 
children. 

The exact pathology of diabetes insipidus is not known ; hut 
from the conditions under which it occurs it is believed to be a 
neurosis. 

Etiology. — Of eighty-five cases collected by Strauss, twenty-one were 
in children under ten years of age and nine under five years. In Rob- 
erts's collection of seventy cases, the disease began in twenty-two chil- 
dren before ten years, and in seven during infancy. In some cases it 
begins soon after birth. Males are more frequently affected than females, 
and in certain cases heredity is an important factor. Weil has published 
a remarkable example of the disease existing in many members of a 
single family. Falls or blow r s upon the head, concussion of the brain, 
tumours of the brain, especially of the occipital region, or chronic hydro- 
cephalus, all have been found associated with diabetes insipidus. It 
sometimes has followed the acute infectious diseases; but in many cases 
no cause whatever can be found. 

Symptoms. — The quantity of urine is enormous, usually exceeding 
even that in diabetes mellitus. From five to twenty pints daily may be 
passed. The urine is pale, the specific gravity from 1.001 to 1.006, and 
it contains neither albumin nor glucose. In a few cases the presence of 
inosite (muscle sugar) has been found. Restricting the amount of fluid 
taken causes a very marked diminution in the amount of urine. The 
intense thirst leads patients to drink enormously of water and other 
fluids. 

Nervous symptoms are usually present. There may be disturbed 
sleep from the frequent micturition, palpitation, flushing of the face and 
other vaso-motor disturbances, headache, restlessness, and neuralgia. 
There may be incontinence of urine. The bladder sometimes becomes 



606 DISEASES OF THE URO-GENITAL SYSTEM. 

enormously distended. In one of ray cases ii held forty-five ounces and 
reached above the umbilicus. The skin is pale and dry, and perspiration 
is scanty. The general health may not be disturbed. In most cases, 
however, it is somewhat affected, and there may he the usual symptoms 
o( malnutrition, and even neurasthenia. 11* it affects young children, 
their growth may be retarded. The appetite usually remains quite 
good. The temperature is at times slightly subnormal. The course of 
the disease is indefinite. It is very chronic, and may last for many years, 
death taking place only from intercurrent affections. 

Prognosis. — A few of the cases recover spontaneously. Those of short 
duration are often cured by treatment. Of the chronic cases in which 
the disease is well established very few are controlled. The prognosis is 
worse if there are marked disturbances of the digestive tract or organic 
brain disease. 

Diagnosis. — This is easily made from the two marked symptoms, ex- 
cessive thirst and polyuria. From diabetes mellitus it is easily distin- 
guished by the lower specific gravity and the absence of sugar from the 
urine. In older children, chronic nephritis with contracted kidney may 
be confounded with it. 

Treatment. — Fluids should be moderately restricted. It is a serious 
mistake to reduce the quantity of fluids too much, since the drinking is 
not the cause of the diuresis. The diet should be simple and nutritious. 
The general treatment should be directed to the condition of malnutri- 
tion. The clothing should be warm, and a moderate amount of exercise 
should be allowed. Drugs, in most cases, are of little use; but decided 
improvement has sometimes followed the prolonged use of codeine; other 
cases have been benefited by the bromides and belladonna. Treatment 
must be continued for many months to be of any value. 



CHAPTEE II. 
DISEASES OF THE KIDNEYS. 

MALFORMATIONS AND MALPOSITIONS. 

Malformations of the kidney are not infrequent. In seven hun- 
dred and twenty-six consecutive autopsies at the New York Infant Asy- 
lum malformations of the kidney or ureters were met with in seventeen 
cases. This does not represent the actual frequency with which they 
occur, for in about half that number of autopsies in two other institu- 
tions only a single example was seen. Adding to the cases mentioned 
two others seen elsewhere, there are twenty cases of renal malformation 
of which I have notes, classed as follows : 



MALFORMATIONS AND MALPOSITIONS OF KIDNEYS. 607 

Fusion of the kidneys, or horseshoe kidney 4 c 

Supernumerary ureters 4 " 

Hydronephrosis (alone) S " 

Congenita] cystic kidney (alone) 2 " 

Hydronephrosis and cystic kidney 1 case. 

Single kidney 1 " 

In all malformations the left kidney is much more frequently affected 
than the right, the proportion being nearly two to one. Malformations 
are more often seen in males than in females. Only two of these con- 
ditions are of clinical importance — viz., cystic degeneration and hydro- 
nephrosis. 

Cystic Kidneys. — Two varieties of this malformation are met with. 
In one the cysts are few in number and large; in the other they are very 
numerous and small. When the cysts are large the renal tumour may fill 
the abdominal cavity, even interfering with the birth of the child. The 
condition is generally bilateral, and the patients die in early infancy. 
The more common form, that with small cysts, also affects both sides 
as a rule. The organ often is not enlarged, and it may even be smaller 
than normal. The surface of the kidney is studded with small cysts, 
which usually vary in size from a pin's head to that of a pea. The en- 
tire organ may consist of nothing but a mass of cysts, held together by 
loose connective tissue. In other cases the cysts are less numerous, and 
much renal tissue remains. The cysts are formed by the dilatation of 
the uriniferous tubules owing to occlusion, which occurs in the devel- 
opment of the kidney. The large cysts are recognised as abdominal 
tumours ; the small ones usually give no symptoms, and are found acci- 
dentally at autopsy in patients dying from other diseases. 

Hydronephrosis. — Of the thirteen cases of which I have notes, this ex- 
isted as the principal deformity in eleven. In two cases it was associated 
respectively with cystic degeneration of the opposite kidney and horse- 
shoe kidney. In seven cases only the left side was affected; in six there 
was double hydronephrosis. Nine patients were males and four females. 
Seven died before they were six months old, and only two lived to be two 
years old. This condition is undoubtedly the result of some obstruction 
to the outflow of urine in the ureter, bladder, urethra, or prepuce, but in 
only three of my cases could there be found an obstruction sufficient to 
explain the deformity. In five there was marked hypertrophy of the 
bladder. In no case was a calculus found as the cause of the ob- 
struction. In most of the cases the ureter was dilated to a diameter 
of from one-fourth to one-half inch, and in five it was so targe as to be 
easily mistaken for the intestine. Usually the ureters appear much 
elongated and sacculated; the pelvis and the calices of the kidney may 
be slightly dilated or the greater part of the kidney may be destroyed, 
leaving only a series of communicating pockets surrounded by a thin 



608 DISEASES OF THE URO GENITAL SYSTEM. 

cortex o( renal tissue. After a time chronic nephritis usually develops. 
This may involve both kidneys, even though the hydronephrosis is uni- 




Fig. 102. — Congenital Hydronephrosis, Dilated Ureters, and Hypertrophied 
Bladder. (From a child one month old.) 

lateral. In two cases, typical examples of the atrophic form (contracted 
kidney) were seen, one of these children dying at the age of one month. 1 
The organs are shown in Fig. 102. 

1 This was in every way a remarkable case. The child died apparently of maras- 
mus. There was double hydronephrosis, the ureters being three-fourths of an inch 
in diameter. The right kidney was nodular upon the surface, and had a very ad- 
herent capsule. Just beneath the capsule there were small cysts containing pus. 
The left kidney was the seat of hydronephrosis, only its cortex remaining, this being 
about one-sixth of an inch in thickness. Microscopical examination showed great 
thickening of the capsule of the right kidney, and several small abscesses situated in 
the cortex just beneath the capsule. The rest of the kidney was converted into a 
mass of dense fibrous tissue in which were scattered many uriniferous tubules. The 



MALFORMATIONS AND MALPOSITIONS OF KIDNEYS. 609 

Urinary symptoms arc noted in but few cases daring Life, and the 
diagnosis is seldom made. The cause of death is usual I \ Bome inter- 
current disease. 

Double hydronephrosis is generally associated with, or results in, 

such changes in the kidneys that the patients die during infancy. It 

may give rise to one or more tumours, which sometimes attain a large 
size. Even when renal tumours can not he made out, the hypertrophied 
bladder may he felt as a hard globular tumour in the hypogastrium. 
Changes in the urine may not he present until the disease is very far 
advanced. There may he the general and local symptoms of chronic 
diffuse nephritis, or, when infection of the genital tract occurs, there are 
added the symptoms of pyelitis. In the great majority of cases the con- 
dition is unrecognised, the patient dying of some disease not perhaps in 
itself fatal, hut rendered so hy the condition of the kidneys. 

If hydronephrosis is unilateral there may he no symptoms until the 
dilatation of the pelvis of the kidney has reached a sufficient size to form 
an abdominal tumour. In most of the cases in children this condition 
has been noted between the third and the eleventh years. This tumour 
may be situated in the lumbar region, or it may fill the abdomen. It is 
cystic, and may be confounded with a dermoid cyst of the ovary. On 
aspiration a fluid is withdrawn which may be clear, or of a brownish 
colour, and recognised as urine by the fact that it contains urates and 
urea. After aspiration the urine passed per urethram may be bloody. 
Aspiration affords only temporary relief, as the tumour quickly refills. 
If an incision is made and the kidney drained, a cure may result with 
the formation of a fistula. This may continue indefinitely, or infection 
of the fistulous tract may occur and suppurative nephritis be set up, 
which speedily carries off the patient. A better operation is nephrec- 
tomy, which may result in a permanent cure if the opposite kidney is 
healthy, which is usually the case if the child is over three years of age, 
for the reason above stated, viz., that a child with malformation of both 
kidneys usually dies in infancy. 

Movable Kidney. — This is a rare condition in young children. Comby 
has collected eighteen cases, of which sixteen were in girls and two in 
boys. Movable kidney was recognised before the tenth year in eight 
cases, and in two of these before the fourth month. It has been ascribed 
to too long a pedicle, which may be congenital; also to pressure from 
abdominal tumours, and to injury. The most important symptoms are 

left kidney was the seat of chronic diffuse nephritis of the atrophic variety, with well- 
marked changes in the medullary portions. The cortex showed much exudation and 
less atrophy, being nearly normal in thickness. The small size of the organ was due 
chiefly to atrophy of the pyramids. The walls of the bladder were greatly hyper- 
trophied, being in places one-fourth of an inch thick. The urethra and prepuce were 
normal. 

40 



610 DISEASES OF THE URO-GENITAL SYSTEM. 

paroxysmal pain, which may follow exertion, and a movable tumour. A 
twist in the ureter may produce hydronephrosis. 

URIC-ACID INFARCTIONS. 

[These consist in a deposit in (ho straight tubes of the kidneys of uric 
acid or o( amorphous or crystalline urates; usually both kidneys are 
affected, and all the pyramids of each kidney. The infarctions appear 
to the naked eye as line, brownish-yellow, fan-shaped stria?. Associated 
with them there may be granular deposits of uric-acid salts in the pelvis 
o( the kidney, and sometimes evidences of catarrhal inflammation of the 
pelvis, including even the presence of blood. This condition probably 
occurs, to some degree, at least, in nearly all infants during the first ten 
days of life. It was formerly supposed that the discovery of these ap- 
pearances was proof that an infant had breathed, and a certain medico- 
legal importance was therefore attached to them. This is now known 
n<»t to be the case, as they are sometimes found in still-born infants. 

The cause of this condition is the excretion of uric acid before there 
is sufficient water to dissolve it, so that the crystals are deposited in the 
tubes. Uric-acid infarctions are found chiefly in children dying before 
the end of the second week, although it is not uncommon to see them as 
late as the third or fourth or even the sixth month. In most of the 
cases, as the urinary secretion becomes more abundant, the deposits are 
washed out in the urine and appear as browmish-red or pink stains upon 
the napkins. Infarctions may give rise to a slight inflammation of the 
renal tubules, but very rarely to any serious lesion; sometimes they 
remain as deposits in the calices or the pelvis of the kidney or in the 
bladder, forming the nucleus of a calculus. The symptoms to which they 
give rise are mainly scanty urination during the first week of life, and 
occasionally anuria for the first day or two. Sometimes there is evidence 
of severe pain ; priapism may be present, and there is the stain upon the 
napkin already referred to. The treatment is to give water freely and 
some alkaline diuretic such as citrate of potash. One grain should be 
given every two hours until the secretion is fully established; this in most 
cases will be within twenty-four hours. 

CHRONIC CONGESTION OF THE KIDNEY. 

This results from interference with the return circulation of the 
kidney, and may be caused by congenital malformation or valvular dis- 
ease of the heart, chronic broncho-pneumonia or chronic pleurisy; also 
by the pressure of any abdominal tumour upon the inferior vena cava 
or the renal veins. 

The kidneys are generally enlarged, firmer than normal, and dark- 
coloured. All the capillary vessels are swollen and distended with blood, 
and their walls are thickened. In addition to the symptoms of the pri- 



ACUTE DIFFUSE NEPHRITIS. 6] 1 

mary disease, the amount of urine passed is usually scanty and of high 
specific gravity. Albumin and casts are generally present, but are not 

constant. The treatment should he directed toward the primary condi- 
tion, and, in addition, an effort should be made to increase the urine by 
alkaline diuretics, catf'ein, digitalis, and diuretin. 

ACUTE DEGENERATION OF THE KIDNEYS. 

In the succeeding pages devoted to the kidney I have followed in the 
main Prudden's classification. 

In acute degeneration of the kidney the principal or only change is 
in the epithelium of the tubules. It is exceedingly common both in in- 
fancy and in childhood, being found to a greater or less degree in all 
autopsies upon patients dying of acute infectious diseases, hut it is most 
marked in cases of scarlet fever, diphtheria, and acute pleuro-pneumonia. 
It may he found in any disease characterised by prolonged high tempera- 
ture; and it is the explanation of the cases of so-called febrile albu- 
minuria. The cause is in all probability direct irritation of the epithelium 
of the tubules by the toxins eliminated by the kidneys. It may also he 
induced by irritating drugs, such as cantharides or turpentine. By some 
writers these cases have been classed as examples of acute nephritis; hence 
the great discrepancy which exists in statements made as to the fre- 
quency of nephritis in the different infectious diseases. 

The kidneys are usually slightly enlarged, softer, and paler than 
normal. On section the cortex may be somewhat thickened, and the 
straight tubules marked by yellowish-gray lines. It is the appearance 
commonly spoken of as cloudy swelling. The kidneys are seldom much 
congested. The microscope shows a granular degeneration and death of 
the epithelium of the tubules, and when severe this may be accompanied 
by congestion and the exudation of serum. 

Acute degeneration of the kidneys gives rise to no symptoms in addi- 
tion to those of the original disease, except the appearance of a moderate 
amount of albumin in the urine, with a few hyaline, granular, or epi- 
thelial casts. It can not be said that such a condition adds much to the 
danger from the original disease. In cases that recover, the condition of 
the kidney becomes entirely normal. The development of the symptoms 
of degeneration of the kidneys in infectious diseases calls for no special 
treatment beyond a continuance of the fluid diet. 

ACUTE DIFFUSE NEPHRITIS. 

(Acute Interstitial Nephritis; Acute Exudative Nephritis; Glonivrulo-ncphritis; 
Acute Bright' s Disease.) 

Etiology. — This variety of nephritis occurs apparently as a primary 

disease both in infants and in older children. Most such cases are un- 



612 DISEASES OF THE URO-GENITAL SYSTEM. 

doubted ly of infectious origin, although the point o\' entrance of the 
infection may be difficult or impossible to determine. Acute diffuse 
nephritis is very frequently secondary to the acute infections diseases, 
especially to scarlet fever and diphtheria. It occasionally follows 
measles, varicella, empyema, typhoid fever, acute diarrhoea! diseases, 
pneumonia, meningitis, influenza, and malaria. It is the characteristic 
variety o\' secondary nephritis occurring in severe septic conditions. The 
exciting cause o( the inflammation is in some cases the irritation from 
toxins; but usually there is in addition the entrance of pathogenic organ- 
isms carried by the circulation. Tims in post-scarlatinal nephritis, of 
which the one under consideration is the characteristic form, the cause is 
now generally admitted to be the toxins of the primary disease, to which 
in many cases is added infection by the streptococcus. While nephritis 
is more frequent after severe attacks of scarlet fever, it may occur after 
those which are very mild, even when patients have been kept in bed 
throughout the disease. The frequency of nephritis as a sequel of scarlet 
fever varies much in different epidemics ; the average is from six to 
ten per cent. I have seen two cases of acute nephritis in infants, the 
apparent cause of which was the irritation of a highly concentrated urine. 
This was the result of the infants taking for a long time very little 
food, and almost no water. 

Lesions. — In severe cases the kidneys are usually enlarged, soft, and 
cedematous. The capsule is non-adherent. The cortex is thickened, 
either reddened or pale ; frequently it is mottled with red, owing to the 
presence of small haemorrhages. There may be congestion of the entire 
organ ; or the pyramids may seem unusually red by contrast with the pale 
and thickened cortex. 

All the structures of the kidney — glomeruli, tubular epithelium, and 
interstitial tissue — are involved in the inflammatory process. The cells 
covering the glomerular tufts of capillaries are swollen and proliferated. 
They have frequently undergone fatty degeneration and separated. The 
epithelial cells lining Bowman's capsule may undergo the same changes, 
but usually to a lesser degree. The space between the capsule and the 
tuft may contain exfoliated epithelium in considerable quantity, also cell- 
detritus, albuminous (granular) exudate, leucocytes, and red blood-cells. 
The tubular epithelium undergoes albuminous and fatty degeneration 
and may desquamate. Thus the tubules may contain epithelial frag- 
ments, serum, red blood-cells, leucocytes, and casts. The interstitial 
connective tissue is infiltrated with serum and in places with small round 
cells. In cases of longer duration a general increase of the connective 
tissue may take place, which is permanent. 

When the glomerular changes are especially marked, as in acute 
nephritis following scarlet fever, the process is often spoken of as 
glomerulo-nephritis. If the degeneration of the tubular epithelium is 



ACUTE DIFFUSE NEPHRITIS 613 

extreme, aa in Bevere cases of diphtheria dying Bhortly after fche onset, 
the nephritis may be described as the parenchymatous or degenerative 
type. In the hemorrhagic form there are haemorrhages into the tubules, 
glomeruli, or interstitial tissue. In infants and young children the ex- 
udative type of acute diffuse nephritis is especially frequent. In this 
there is an exudative 4 inflammation with large accumulations of leucoc] 
serum, and red blood-cells in the glomeruli and tubules, the parenchyma 
and interstitial tissue sometimes being markedly and sometimes hut 
slightly changed. Should the interstitial tissue Buffer early and severely, 
the nephritis becomes of the productive or interstitial type. This form is 
most frequently seen with severe, protracted cases of scarlet fever and 
diphtheria, 1 especially in older children. It sometimes occurs as an ap- 
parently independent process. 

Symptoms. — 1. Primary Form in Infant*. — These cases are not com- 
mon, and the symptoms are so obscure that they are often overlooked. 
At least ten such cases have come under my observation. The inflamma- 
tion in most of them was of the exudative type. 

The onset in nearly every instance was abrupt, usually with high 
fever and vomiting, the temperature being in several cases over lot F. 
Dropsy was very exceptional, being noted in but six cases; in most of 
these it was slight, and seen only toward the (dose of the disease. Fever 
was present in all cases. In those observed by myself it was high and 
irregular in type, ranging from 101° to 105° F. The duration of the 
disease was from eight days to four weeks, the average being about two 
and a half weeks. Vomiting and diarrhoea were noted in half the cases, 
but were rarely prominent, and marked either the onset of the attack, 
or were traceable to indigestion accompanying the fever; very rarely did 
they exist as symptoms of uraemia. Anaemia was a prominent symptom 
in nearly every case, and it was this which enabled me in several instances 
to make a correct diagnosis. Nervous symptoms were usually prom- 
inent. In several patients there was dyspnoea without pulmonary dis- 
ease, partly due, no doubt, to the anaemia. In nearly all cases there was 
marked restlessness or muscular twitchings, and in three there were con- 
vulsions. Dulness and apathy were present in the majority of the fatal 
cases, but deep coma was never seen. Several patients presented the 
typical symptoms of the typhoid condition. The urine was rarely scanty 
until near the close of the disease, and sometimes not even then. Sup- 
pression of urine occurred in but a few cases. Albumin was frequently 
absent early in tin 1 attack, but was invariably present at a late period, 
although rarely in large amount. Casts were found in all cases that were 
carefully examined microscopically. They were not usually numerous, 

1 Councilman, Mallory, and Pearce, Diphtheria: A Study of the Bacteriology and 
Pathology of Two Hundred and Twenty Fatal Cases. 1901. 



614 DISEASES OF THE TOO-GENITAL SYSTEM. 

and were chiefly o( the hyaline, granular, and epithelial varieties. No 
blood casta were seen. There were usually many pus rolls and renal 
epithelial rolls, together with rod blood-cells in moderate cumbers. 

Of the twenty-four cases, sixteen died and eighl recovered. Of my 
own ten cases, nine were fatal, the diagnosis being confirmed by autopsy 
in every case bul two. Whether those figures represent the actual mor- 
tality of the disease it is difficult to say. No doubt there are man}' mild 
cases which are unrecognised. The severe ones, however, are quite uni- 
formly fatal, chiefly on account of the tender age of the patients. 

'2. Primary Form in Older Children. — This also is a rare form of 
renal disease. As compared with the same condition in infants, the onset 
is usually less abrupt, the febrile symptoms are less marked, and the ter- 
mination is less frequently fatal. Dropsy is rarely marked, and often 
there is none at all. The urine is only slightly diminished in quantity; 
the amount of albumin is small; casts are not numerous, and usually 
hyaline, epithelial, or granular; very rarely is there much blood present. 
Uraemia is infrequent, and the prognosis is better than in infancy. 

The interstitial type may begin abruptly with febrile symptoms, 
dropsy, headache, lumbar pains, scanty urine, and often with vomiting; 
or it ma}' come on somewhat insidiously with few constitutional symp- 
toms, but with dropsy and changes in the urine. 

3. Secondary Form. — The secondary nephritis of acute infectious dis- 
eases may occur at the height of the febrile process or at a later period, 
and its severity is generally proportionate to the intensity of the infection. 
The general symptoms of nephritis are often not marked, and dropsy 
is rare ; so that unless the urine is examined the condition may be over- 
looked. The urinary changes are essentially the same as those already 
mentioned in the primary cases. Suppression of urine and the develop- 
ment of the symptoms of acute uraemia are infrequent. While nephritis 
adds considerably to the danger from the primary disease, it is seldom 
itself the cause of death, although this is sometimes the case in scarlet 
fever or diphtheria. 

The characteristic type of nephritis which follows scarlet fever most 
frequently develops during the third or fourth week of the disease. The 
onset may be gradual, dropsy being first noticed. Or it may begin ab- 
ruptly without dropsy, but with headache, vomiting, scanty urine, fever, 
and even convulsions. The temperature generally ranges from 100° to 
101 .5° F., but in very severe attacks it may be 104° or 105° F. While 
dropsy is usually present, it may be slight or absent in severe and even in 
fatal cases. It is first seen in the face, next in the feet, legs, and scrotum ; 
there may be general anasarca, with dropsy of the serous cavities of the 
body, the pleura, or the peritonaeum, rarely the pericardium. As the 
disease progresses there is always a very marked degree of anaemia. 

The urine is, as a rule, greatly diminished in quantity, and may be 



ACUTE DIFFUSE NEPHRITIS. 615 

suppressed. Albumin is invariably present, although not always at firsi ; 

it is usually in large amount, often enough fco render the urine solid 
upon boiling. The urine is of a dark, reddish-brown or smoky colour. 
owing to the presence of red hlood-cells or haemoglobin. The total 
amount of urea eliminated is far below the normal. The specific gravity 
may be low, even though the quantity is very small. Casts are present 
in great numbers, chiefly hyaline, granular, and epithelial casts from the 
straight tubes; not infrequently there are blood casts. Red blood-cells 
are present in great numbers; also many leucocytes, and penal epithelium. 

The duration of the active symptoms in cases terminating in recovery 
is from one to three weeks. The temperature and dropsy gradually sub- 
side. Improvement in the urine is shown by an increase in quantity, by 
an increased elimination of urea, and by a diminution in the amount of 
blood, albumin, and the number of casts. A few casts may persist for 
several weeks, and a small amount of albumin for two or three months. 

In the graver cases, when the onset is accompanied by high temper- 
ature, pain in the back and loins, and a rapid, full pulse of high tension, 
the urine is very scanty and is often suppressed. Then follow the symp- 
toms of uraemia. In children this is usually manifested by vomiting, 
great restlessness or apathy, and often by diarrhoea. Less frequently 
there is headache, dimness of vision, stupor developing into coma, or 
convulsions. If the secretion of urine is re-established, the nervous symp- 
toms abate and the patient may recover. This has been known to occur 
after complete suppression has lasted thirty-six hours. Care should be 
taken not to mistake retention for suppression. If doubt exists, percus- 
sion of the bladder and the use of the catheter will quickly settle the 
question. 

There are several complications for which the physician must con- 
stantly be on the lookout during attacks of acute nephritis; the most 
frequent are pneumonia, pleurisy, pericarditis, and endocarditis; more 
rarely there may be meningitis and oedema of the glottis. It is from 
complications or acute uraemia that death usualty occurs. 

Prognosis. — This is to be considered from two points of view: first, 
the danger to life during the acute stage of the disease, and, secondly, 
the danger of the development of chronic nephritis. The great majority 
of patients survive the acute stage, and not infrequently even those re- 
cover who have presented grave symptoms of ursemic poisoning. The 
quantity and specific gravity of the urine, and the number and variety of 
the casts, are a much better guide in prognosis than the amount of albu- 
min. The existence of severe nervous symptoms, such as stupor, intense 
headache, dimness of vision, and persistent vomiting, add much to the 
gravity of the case, as does also the presence of any serious complication. 
In general it may be said that if there is no suppression of urine, or if 
there are no symptoms of uraemia and no complications, recovery is 



616 DISEASES OV THE URO GENITAL SYSTEM. 

almost certain if the child is over three years old; in younger children 
the outlook is less favourable. The general opinion prevails thai acute 
diffuse nephritis in childhood, whether it is primary or occurs as a com- 
plication o( scarlet fever, is rarely followed by the chronic form of the 
disease; and such was the view I formerly held. Larger experience, 
however, has convinced me thai this sequel is not very uncommon. The 
interval o( apparent health may sometimes cover a period of several 
years, and the later nephritis may be attributed to other causes; but all 
cases of scarlatinal nephritis should be carefully watched for a long time, 
and after a severe attack a guarded prognosis should always be given 
as regards the ultimate result. 1 

Treatment. — Prophylaxis is important, and relates principally to the 
secondary form which occurs in the course of infectious diseases, espe- 
cially post-scarlatinal nephritis; but the measures here outlined apply 
equally to all varieties. The inflammation of the kidney being in most 
of these cases the result of direct irritation by the toxins which are elim- 
inated by them, it follows that elimination through the skin and intes- 
tines should be increased, and that the urine should be rendered as little 
irritating as possible by largely increasing its quantity. The first indi- 
cation is met by frequent sponging, warm baths, and keeping the bowels 
freely opened by saline cathartics, sufficient being given to produce one 
or two loose movements daily. To meet the second indication, the pa- 
tient should be kept upon a diet of milk and farinaceous food, at least 
for the three weeks of the disease, and, if possible, for a full month. 
At the same time he should drink very freely cf alkaline mineral waters, 
or of plain water. If milk is not well borne, kumyss, whey, buttermilk, 
or junket may be used, or thin gruels mixed with milk. When the first 
trace of albumin appears in the urine this plan of treatment should in- 
variably be followed. In addition to these measures, after an attack of 
scarlet fever the patient should be kept in bed for at least a week after 
the temperature has become normal. 

The mild cases of acute nephritis tend to spontaneous recovery under 
the hygienic and dietetic treatment outlined, i. e., rest in bed, the diet 
mentioned, the drinking of large quantities of water, and attention to the 
action of the skin and bowels. These measures should be continued so 
long as the urine contains any considerable amount of albumin, or so 
long as the patient's general condition will permit. Should he become 

1 The following case may be cited as an illustration of this point: A girl at the age 
of seven years had scarlet fever, followed by nephritis; the dropsy having lasted, it 
was reported, for three months. She was believed to have recovered perfectly, and 
remained in apparent health until she was sixteen, when, as a supposed result of a 
severe chilling, she developed dropsy and all the symptoms of acute nephritis. From 
that time, although she lived for three years, and was often for months at a time 
seemingly in the best of health, her urine was never free from casts and albumin, and 
she finally died in uraemic convulsions. 



ACUTE DIFFUSE NEPHRITIS. 617 

very anaemic, or lose much in weight, it may be accessary to enlarge the 

diet by the addition of more solid food. An increase in the diel and 
exercise should be made very gradually, and the effed upon the urine 
carefully Matched. 

The severe cases, with scanty urine, fever and marked dropsy, re- 
quire more active treatment. Free diaphoresis should he maintained \>y 
the hot pack or vapour bath. Active counter-irritation should be main- 
tained over the kidneys by dry cups followed by poultices, or the mustard 
paste. Two or three loose movements Erom the bowels should be secured 
by the administration of calomel or, better by Rochelle or Epsom salts. 
Harm is sometimes done by carrying this depletion too far, and its effect 
upon the patient's general condition must be closely watched. If sup- 
pression of urine occurs with the development of urasmic symptoms — 
delirium, high temperature, flushed face, vomiting, and a pulse of high 
tension — nitroglycerin is indicated: a child of five years may take gr. 3 ,',„ 
every hour for five or six doses, or until an effect is produced. 

In addition to these measures rectal injections of a normal sail solu- 
tion should he given high in the colon, at a temperature of from 10 1° 
to 108° F. At least two quarts should he given several lines a day, to he 
continued until a free flow of urine is established. This is one of the 
most valuable means we possess of increasing elimination by the kidneys 
and skin. 

The nervous symptoms of uraemia are best relieved by chloral, which 
should be given per rectum. When such symptoms are marked, from 
six to ten grains are required for a child of five years, to he repeated 
in two hours if no improvement is seen. UraEmiic convulsions may some- 
times be averted by the use of morphine hypodermically. In extreme 
conditions not relieved by the measures mentioned, venesection should 
by all means be practised; from three to six ounces of blood may he drawn 
from a child of five years, according to his general condition and the 
urgency of the symptoms. The depressing effect may largely be overcome 
by immediately following this with an intravenous injection of a normal 
salt solution. Twice as much as the fluid drawn should be introduced. 
This will almost invariably give at least temporary relief, which may 
afford time for the operation of other measures such as catharsis and 
diaphoresis. Pulmonary oedema is no centra-indication to bleeding; 
the best of all guides as to its use is a pulse of very high tension. 

One should always be on the lookout for complications, especially 
dropsy of the serous cavities, pericarditis, and oedema of the lungs. Con- 
valescence is nearly always slow, and a patient who has suffered from 
nephritis needs careful attention for a long time. Anaemia is always 
present, and iron is required. The diet should be carefully restricted 
for several months; much nitrogenous food should he avoided. If the 
disease tends to pass into a subacute form, the child should, if possible, 



618 DISEASES OF THE URO-GENITAL SYSTEM. 

be sent to a warm climate, and kept there during the succeeding winter, 
and every means takes to improve the general nutrition. Flannels 
should l>e worn next to the skin, and special precautions taken against 
any exposure which might cause an exacerbation of the disease. 

CHRONIC NEPHRITIS. 

Chronic inflammation of the kidney is an infrequent condition in 
childhood. In infancy it is almost unknown, except in connection with 
congenital hydronephrosis or other malformations of the kidney. Two 
pathological varieties are met with: (1) chronic diffuse nephritis of 
the parenchymatous or degenerative type; (2) chronic diffuse nephri- 
tis of the interstitial or productive type. As the disease progresses the 
former may assume the characteristics of the latter variety. 

Etiology. — Chronic nephritis is most frequently seen as a sequel of 
the acute nephritis of scarlet fever, less often after other acute infections. 
The only other important causes in early life are hereditary syphilis, 
chronic tuberculosis, and valvular disease of the heart. Xearly all the 
cases occur in children over five years of age. 

Lesions. — The lesions of chronic nephritis in childhood do not differ 
essentially from those seen in later life. In the chronic parenchymatous 
type the kidneys are usually enlarged, the surface is smooth or slightly 
nodular, and the thickened cortex yellow r ish-white on section. These are 
often called " large white kidney s." On the other hand, the kidneys 
may he nearly normal in appearance, or smaller and with a thinner cortex 
than is usual. In the so-called " large red kidneys " the cortex is red or 
mottled red and yellow, owing to haemorrhages into the tubules or in- 
terstitial tissue. The microscope show r s that the renal epithelium is 
swollen, granular, fatty, and degenerated. The tubes contain leucocytes, 
red cells, east matter, and the detritus of broken-down epithelial cells. 
In some places they are dilated, in others atrophied. In the glomeruli 
there is a growth of capsule cells, compression and atrophy of the tufts, 
with the formation of new connective tissue. 

In the chronic diffuse nephritis of the interstitial type (granular 
kidney) the organs are smaller than normal, with a nodular surface and 
adherent capsule. The cortex is thinned, and the colour is gray or red. 
In addition to the lesions found in the preceding variety, there is an 
extensive production of new connective tissue, which is irregularly dis- 
trihuted throughout the kidneys. The tubules in some places are dilated 
to form cysts of considerable size, while in others they have completely 
disappeared. The glomeruli may he atrophied to little fibrous balls; 
or ii chronic congestion has preceded the inflammation, some may be 
large and the capillaries dilated with hyaline degeneration of their 
walls. 



CHRONIC NEPHRITIS. 619 

Symptoms. — 1. Chronic Nephritis of the Parenchymatous Type, — 
This form of the disease may be chronic from the outset, or follow an 
acute attack from which the patient is often believed to have recovered 
completely. The symptoms sometimes immediately follow the acute 
attack; at others there is an interval of apparent recovery, extending 
over a few months or even years. Very rarely no such history of an 
antecedent acute attack can be obtained, and the symptoms come on 
gradually and insidiously. Such cases occur chiefly in older children, 
and their clinical features do not differ essentially from those of adult 
life. 

As a rule dropsy is present, although it is variable in amount, and 
fluctuates considerahly from time to time. There may be not only 
oedema of the cellular tissue, but effusion into the pleura, peritonaeum, 
and even the pericardium. As the case progresses, anamiia is always a 
marked symptom. There are various disturbances of digestion — loss of 
appetite, occasional vomiting, and attacks of diarrhoea. From time to 
time nervous symptoms may be quite prominent, such as headaches, sleep- 
lessness, neuralgia, fatigue upon slight exertion, and dyspnoea. Attacks 
of epistaxis are not infrequent. 

For the greater part of the time the urine contains albumin and 
casts. They vary much in amount at different periods in the disease, 
according to the rapidity of its progress. During periods of exacerbation, 
both albumin and casts are very abundant, while in the intervals the 
amount of albumin may be small and the casts few. The casts are 
hyaline, granular, epithelial, and fatty. The daily quantity of urine is 
much reduced during the periods of exacerbation, while at other times 
it may be nearly normal. The specific gravity is usually normal or high. 

If amyloid degeneration is present, there are generally associated with 
the renal symptoms, others dependent upon amyloid changes in other 
organs. The spleen and liver are enlarged; there may be ascites and 
diarrhoea, and there is usually present a peculiar alabaster cachexia. 

The duration of this form of chronic nephritis depends much upon 
the surroundings of the patient and the treatment. It is rarely shorter 
than two years, and it may last for many years. The progress is always 
irregular, and marked by periods of exacerbation and remission. The 
patients die from acute uraemia, from some intercurrent disease, or from 
complicating pneumonia, pleurisy, pericarditis, endocarditis, or from 
pulmonary oedema. 

2. Chronic Nephritis of the Interstitial Type. — This is a very rare 
disease in early life, being much less frequent even than the preceding 
variety of nephritis. In some cases there is a history of hereditary 
syphilis; in others, of chronic alcoholism. The early symptoms are few. 
and the disease usually develops insidiously. The urine is pale, exces- 
sive in amount, and of low specific gravity — 1 .001 to 1 .008. Albumin 



620 DISEASES OF THE URO-GENITAL SYSTEM. 

is often absent, and, when found, the quantity is small. Dropsy like- 
wise is rare, and oever marked. Nervous symptoms are often prominent, 
such as headache, attacks of spasmodic dyspnoea resembling asthma, 
neuralgias, ami disturbances of vision. High arterial tension and hyper- 
trophy of the left ventricle are regular symptoms; and even atheroma- 
tous degeneration of the arteries may be present. Dickinson reports an 
instance of this in a patient only six years of age. Late in the disease, 
haemorrhages may occur, and these may be the cause of death. Filatoff 
has reported a cerebral haemorrhage in a child of eleven years. Acute 
uraemia is, however, the usual termination of this form of nephritis. 
The course is slow, and the disease may be overlooked until the final 
uraemic symptoms occur. 

Prognosis. — The prognosis of chronic nephritis as to complete re- 
covery is always unfavourable; and although cases are seen in which 
symptoms are absent for several years, they almost invariably return. 
As to the duration of the disease, no exact prognosis can be given, because 
from the symptoms, it is difficult or impossible to determine exactly the 
extent of the disease in the kidney and the rapidity of its progress. The 
continued passage of a large amount of urine of low specific gravity is in- 
variably to be interpreted as evidence of fibroid changes in the Mal- 
pighian tufts, and is a bad symptom. A large amount of dropsy, the 
coexistence of valvular disease of the heart, and marked renal insuf- 
ficiency, as show r n by the quantitative examination of the urine, are all 
very unfavourable symptoms. 

Diagnosis. — Chronic nephritis, like the acute forms, is likely to be 
overlooked because of the failure to examine the urine in children. 
Regular and frequent examinations should be made in all cases of con- 
vulsions, of persistent or frequent headaches, severe anaemia, hypertrophy 
of the heart, high arterial tension and of general malnutrition, as well 
as when the more obvious symptoms of renal disease, such as dropsy and 
scanty urine, are present. Nor should one be too ready to make the 
diagnosis of functional albuminuria because he finds albumin only oc- 
casionally and in small quantity. All such cases demand most careful 
observation and the closest attention for a long period before excluding 
organic renal disease. 

Treatment. — Children with chronic nephritis are to be treated on the 
same general plan as adults. The purpose of treatment is to retard as 
much as possible the progress of the disease and to relieve the symptoms 
as they arise. It is of the greatest importance to remove the patient 
from conditions in which exacerbations are liable to occur. If it is pos- 
sible, he should be sent to a warm, dry climate in winter, and all exposure 
to cold avoided ; an out-door life is desirable. Most patients require gen- 
eral tonic treatment with very moderate hut regular exercise, never car- 
ried to the point of fatigue, as much rest as possible in a recumbent 



TUBERCULOSIS OF THE KIDNEY. 621 

position, a fluid diet, consisting Largely of milk as long as this can be 
borne, and the administration of iron. Dropsy calls for a sail live diet, 
diuretics, saline cathartics, and vascular stimulants. If uraemia de- 
velops, with high arterial tension and stupor, headache, and convulsions, 
venesection should be resorted to, or nitroglycerin used. Morphine ma} 
be given hypodermically if the nervous Bymptoms are very marked. 

Decapsulation of the kidney is to be considered in cases growing 
progressively worse in spite of medical treatment. The immediate risks 
of the operation are rather less than would be expected. 1 have seen 
striking temporary benefit in several cases when this operation was done 
upon young children. In no case, however, was the improvement per- 
manent, all the patients dying within a year after it was performed. 

TUBERCULOSIS OF THE KIDNEY. 

In general tuberculosis, miliary tubercles are frequently seen both 
upon the surface of the kidney and in its substance. These give rise to 
no symptoms and are of no clinical importance. Larger tuberculous 
deposits are extremely rare in early life. They usually occur in patients 
who are the subjects of general tuberculosis, and are associated with 
tuberculosis of other parts of the genito-urinary tract, or they may exist 
as the primary, or even the only, tuberculous lesion in the body. Ascend- 
ing infection occurs occasionally but it is rare; nearly all cases are of the 
descending type, i. e., primary in the kidney. Infection of the kidney 
therefore generally takes place through the circulation and not from the 
bladder. Aldibert's figures show that in children the bladder usually 
escapes even when the kidneys are tuberculous, for of thirteen cases of 
renal tuberculosis the bladder was involved in but two. The disease when 
primary begins in the cortex, but soon extends to the mucous membrane 
of the pelvis and the calices of the kidney, and also to the pyramids. 
As a rule, but one kidney is affected. The process may be confined to 
the pyramids, where are found cheesy nodules which may be single or 
multiple. These ultimately break down and form abscesses. The process 
may result in almost complete destruction of the pyramids, and even of 
portions of the cortex, so that the kidney may consist of a mere shell of 
renal tissue. Suppuration in the neighbourhood of the kidney (peri- 
nephritic abscess) often coexists. 

The symptoms are quite indefinite. There may be localised pain and 
tenderness in the region of the kidney, and a tumour if there is peri- 
nephritis. The symptoms of irritability of the bladder may he almost as 
severe as in cases of calculus. Pus usually apj)oars in the mine as a con- 
stant symptom, and blood is often present. Hut the only thing that is 
diagnostic is the discovery of tubercle bacilli in the mine. 

The treatment is the same as in ad nils. 



622 DISEASES OF THE URO (iKNITAL SYSTEM. 



MALIGNANT TUMOURS OF THE KIDNEY. 

In the great majority of cases tumours of the kidney are malignant. 
Of fifty-one cases collected by Aldibert which were operated upon, forty- 
eighl were malignant, and three benign. 

Malignant growths are almost invariably primary. In children under 
five years, although not common, they are yet more frequent than any 
other variety of malignant tumour of the abdomen. The earlier cases 
reported were classed as carcinoma. It is now well established that car- 
cinoma is very infrequent, and that nearly all the cases are varieties of 
sarcoma. The tumour grows from the cortex of the kidney, or from the 
pelvis, sometimes from the adrenals. It may infiltrate the whole kidney, 
so that there is no trace of renal structure remaining, or it may form 
an immense tumour on one side of the kidney, which is only partially 
invaded. These tumours are very rarely cystic, but they are quite soft, 
and haemorrhages often occur into their substance. There may be sec- 
ondary growths in the liver, the lungs, the retroperitoneal glands, in the 
opposite kidney, in the intestines, or in the pancreas. Pressure of the 
tumour upon the ureter may lead to hydronephrosis, and upon the in- 
ferior vena cava, to thrombosis of that vessel. As it grows, the tumour 
sometimes becomes adherent to nearly all the abdominal organs by 
localised peritonitis. It may lead to ascites, but it very rarely causes gen- 
eral peritonitis. The growth may reach a great size, usually from five to 
fifteen pounds, but in one case reported by Jacobi it weighed thirty-six 
pounds. In Seibert's collection of forty-eight cases the right kidney 
was involved in twenty-four, the left in twenty-two, and both kidneys 
in two cases. 

Etiology. — These tumours of the kidney may be congenital. This 
was true of 5 cases in a series of 55 collected by Jacobi. The majority 
occur in early childhood. In the collection of 130 cases by Longstreet 
Taylor in which the ages are given, 106 were observed during the first 
five years, and 57 of these in the first two years of life. The sexes were 
about equally affected. 

Symptoms. — The principal symptoms are tumour, hematuria, and 
cachexia. The tumour is usually first noticed. It is in most cases dis- 
covered in the loin, but grows forward toward the median line. Its sur- 
face may be lobulated and irregular or quite smooth; and although solid, 
it is sometimes so soft as to give an obscure sensation of fluctuation. 
It may grow to an enormous size, causing displacement of the liver, 
spleen, intestines, and lungs. The progress of the growth is usually 
rapid, so that from the size of a fist, the tumour may grow in the course 
of five or six months so as to fill the ahdomen. By careful palpation it 
will be found — certainly when the tumour is small — that although it 
may be quite freely movable, its attachment is near the lumbar spine. 



MALIGNANT TUMOURS OF TIIK KIDNEY. 



623 



Hematuria may be the first symptom noticed. The amount of blood 
passed is sometimes quite large, bul is usually small, and may be discov- 
ered only by the microscope. Pain is rare, and is due to localised pen 
tonitis. Constitutional symptoms are absenl until the tumour has at- 
tained a large size, when a cachexia develops and the patient wastes 
steadily while the tumour continues to grow. The pressure effects 
are dyspnoea, from compression of the lungs; (edema of the lower 
extremities, from pressure upon or thrombosis of the vena cava; 
vomiting and indigestion, from pressure upon the stomach and in- 
testines. Secondary de- 
posits very rarely cause 
any symptoms except in 
the lungs, where they may 
give rise to cough, and even 
to haemoptysis. 

The course of the dis- 
ease is steadily from bad to 
worse. The usual duration 
of life in patients not op- 
erated upon is from three 
to ten months after the tu- 
mour is large enough to be 
easily discovered. 

Diagnosis. — The impor- 
tant points are, the position 
and attachment of the tu- 
mour, its steady growth 
and solid character, hema- 
turia, and the age of the 
patient (under five years). 
It may be confounded with 
hydronephrosis, dermoid 
cyst of the ovary, enlarge- 
ment of the spleen, retro- 
peritoneal sarcoma, tu- 
mours of the liver, or even 
of the abdominal wall. 

Treatment. — Nothing is 
to be said regarding the 
medical treatment of these 

cases. Unless operated upon, they invariably terminate fatally. Some 
of the results of operation during recent years have been so encour- 
aging that no case should be abandoned, no matter how young the 
patient, but recurrence in the opposite kidney is probable. 




Fig. 103. — Sarcoma of the Kidney. Child thir- 
teen months old. Weight of tumour, seven 
pounds. This patient was followed for .sixteen 
years and there was no recurrence. 



(>24 DISEASES OF THE URO-GENITAL SYSTEM. 

Benign Tumours. — These are distinguished by their slow growth, 
and by the fact that the constitutional symptoms arc mild or wanting. 
Of the three rases mentioned by Aldibert, one was adenoma, one fibroma, 
and one was fibro-cvstic. 



PYELITIS— PYELO-CYSTITIS. 

Pyelitis is an inflammation of the mucous, membrane lining the pel- 
vis o\' ilif kidney; cystitis is an inflammation of the mucous membrane 
of the bladder. They may exist separately or together. With pyelitis 
there may he inflammation of the ureter or of the kidney itself (pyelo- 
nephritis), and it may be acute or chronic. It may result in the accu- 
mulation of pus in considerable amount in the pelvis of the kidney 
(pyonephrosis). 

Etiology. — The most frequent local cause of pyelitis is irritation from 
renal calculi. It is also associated with congenital malformations of 
the kidneys or ureters, with renal tuberculosis and renal tumours. It 
may result from an extension of inflammation from the tissue? sur- 
rounding the kidney (perinephritis), or from an abscess opening into 
the pelvis of the kidney. Acute pyelitis sometimes occurs as a compli- 
cation of scarlet or typhoid fever, diphtheria, influenza, or pyaemia; but 
it is also seen apart from these diseases, when it occurs apparently as a 
primary affection. In most of the severe cases of pyelitis there is also 
present a certain amount of nephritis. 

Acute pyelitis in young children is usually due to an ascending in- 
fection from the bladder. In these cases the evidences of inflammation 
of the bladder are slight or, more frequently, entirely wanting. This 
form of inflammation occurs almost invariably in female infants. Cul- 
tures made from the urine have shown with great uniformity the pres- 
ence of the colon bacillus. In many of the cases the pyelitis is preceded 
by an attack of diarrhoea. It is surprising that vulvo-vaginitis is seldom 
present. It seems quite possible that infection may also occur, especially 
in male infants, by a direct extension from the intestine to the bladder, 
or through the blood. Trumpp examined the urine in sixteen patients 
with gastro-enteritis and found the colon bacillus in thirteen, of whom 
nine were females. 

Lesions. — When pyelitis develops from a local cause it is usually 
unilateral; otherwise both sides are involved. In the cases of acute 
cystitis or pyelo-cystitis there are the usual appearances of an acute 
catarrhal inflammation of the mucous membrane, with congestion, swell- 
ing, and sometimes minute haemorrhages. In chronic cases there is 
thickening and sometimes a granular condition of the lining membrane. 
There may be an accumulation of pus of considerable size, distending 
the pelvis and calices (pyonephrosis). If the condition is one depend- 



PYELITI&-PYELO-CYSTITIS. ( }25 

ing upon a calculus or congenital deformity, and in all protracted and 
severe cases, the kidney itself is involved to a greater or leas degree; the 
extent of the nephritis will depend upon the nature of the exciting cause 
and the duration of the process. 

Symptoms. — The history of the following case illustrates the main 
clinical features of acute infectious pyelitis, in this instance occurring 
apparently as a primary disease : 

A previously healthy female infant of eight months was taken sud- 
denly with a chill, followed by a very high fever. The child was ill for 
ten days before the nature of the disease was suspected. During this 
time the temperature ranged between 101° and 106° F., touching 105° 
nearly every day ; but the chill was not repeated. The other constitu- 
tional symptoms were not severe. At the first examination of the urine 
there was found a large amount of pus, which on standing was equal to 
one-twelfth of the volume of the urine passed ; the reaction was strongly 
acid. There were no signs of vaginitis or vulvitis, no ardor urince, no 
evidence of local pain either in the bladder or kidney, no abnormal fre- 
quency of micturition, no localised tenderness, and no vomiting. At 
later examinations there were found in moderate numbers epithelial cells 
from the bladder, and the tubules and pelvis of the kidney, also a few 
hyaline casts, but not more albumin than would be explained by the 
amount of pus. Under no treatment except alkaline diuretics, the tem- 
perature gradually fell to normal, and the pus steadily diminished in 
quantity, and at the end of five weeks had practically disappeared from 
the urine. A report sixteen months later stated that the child had re- 
mained well and entirely free from urinary symptoms. 

In some cases there are recurring chills, with wide fluctuations in 
temperature; in others there may be only pyuria, with moderate fever 
and few other constitutional symptoms. The course of the temperature 
is a very irregular one. The fever is seldom continuous, but may be 
interrupted by periods of normal temperature, lasting several days. The 
duration of the acute attack may be from two to six weeks, and pus cells 
may be found microscopically for a much longer time. If the disease 
complicates one of the acute infectious diseases, pyuria may be the only 
symptom. If cystitis is also present micturition is frequent, and may lie 
painful. The urine in acute pyelo-cystitis is turbid from the presence 
of pus, the amount of which may be from one to fifty per cent of the 
volume of the urine. The amount of pus varies greatly from day to 
day. It is often abundant when the temperature is low, and almost 
absent when the temperature is high, this fluctuation depending upon the 
accumulation or the discharge of the pus. The quantity of urine is 
generally somewhat diminished, and it may be quite scanty. The reac- 
tion is usually acid, even though the amount of pus is large. Albumin 
is present in proportion to the amount of pus or the degree of nephritis. 
41 



626 DISEASES OF THE URO-GENITAL SYSTEM. 

Red blood-colls are found under the microscope in most of the very 
acute cases, and may be in sufficient numbers to colour the urine. The 
pus cells in recent cases are usually well preserved, but in old cases they 
may be degenerated. There are many epithelial cells — conical, fusi- 
form, and irregular cells with long tails. There may be renal epithelium 
and hyaline, granular, or epithelial casts, varying in number with the 
severity of the nephritis. In a catheterised specimen the colon bacillus 
is usually present in pure culture. 

In chronic pyelitis only pyuria may be present, or there may be a 
tumour, owing to the pyonephrosis. From time to time, in the chronic 
form, there may be intermittent attacks of acute pyelitis resembling 
those above described. In pyelitis depending upon congenital malfor- 
mations, pyuria is usually the only symptom, unless pyonephrosis is 
present. With calculi we may have acute or chronic pyelitis; there may 
be localised pain, tenderness, sometimes a tumour, occasionally hema- 
turia, and perhaps a history of renal colic or the passage of gravel. 
With tuberculosis, there is chronic pyuria and the presence of tubercle 
bacilli in the urine. The symptoms of general tuberculosis are com- 
monly associated. If there is perinephritis, the inflammation is usually 
acute, and there are present the local symptoms of the original disease. 
If an abscess opens into the pelvis of the kidney, there may be a sudden 
discharge of pus in large quantity with a subsidence of previous local 
symptoms, including the tumour. With neoplasms, both pus and blood 
may be found in the urine, but the latter is more frequent. 

Diagnosis. — The characteristic symptoms of acute pyelitis are chills, 
which may be repeated, high and fluctuating temperature, scanty urine, 
frequently pain and tenderness over the kidneys, and pyuria. The diag- 
nosis of pyelitis is made only by an examination of the urine, which 
should never be omitted in cases of obscure high temperature, even in 
infancy, particularly if chills are present. ^Vhen c} r stitis is associated, 
the only additional symptoms may be pain and other signs of vesical 
irritation. These symptoms, with an acid urine containing a large 
amount of pus and epithelial cells like those described, are sufficient to 
establish the diagnosis of pyelo-cystitis. If the pus comes from the 
opening of an abscess into the bladder, ureter, or pelvis of the kidney, 
the local signs of such abscess will usually be present. 

Prognosis. — In cases apparently primary, and in those complicating 
infectious and other diseases, the prognosis is good. The danger is 
chiefly from the nephritis which follows or complicates the process. In 
cases depending upon local conditions, the prognosis will depend upon 
the nature of the exciting cause. Here, also, the principal danger is 
from nephritis. If calculi are present and if pyonephrosis occurs, the 
patient may die from exhaustion before a serious degree of nephritis 
has developed. 



RENAL CALCULI. 627 

Treatment. — Water should be given freely, and alkalies up to t he 
point of neutralising the excessive acidity of the urine. In infants, from 

fifteen to twenty-five grains of the citrate of potash are required daily 
for this purpose. If the urine is alkaline, benzoic acid may be used in 
the same doses. The most widely used remedy is uexamethylenamine 
(urotropin), which may be given in doses of one or two grain- 
three hours to an infant of a year, and proportionate doses to older chil- 
dren. I have seen it used in large and small doses in cases of acute 
pyelitis, hut have not been convinced of its value, mosl cases promptly 
recovering without it. Occasionally pyelitis is very resistent to any form 
of treatment, the exacerbations and remission- continuing for many 
weeks. For such obstinate cases vaccines, preferably the autogenous 
variety, should he tried. Striking benefit has sometimes followed their 
use. If calculi are present the same treatment is indicated. Surgical 
interference is called for if pyonephrosis develops, or if the disease is 
evidently unilateral and the kidney is seriously involved. The advis- 
ability of surgical interference will depend upon the clearness of diag- 
nosis and the severity of the symptoms. 



RENAL CALCULI. 

Small renal calculi are very common in infancy. In the autopsy 
room we frequently see, on opening the kidneys of young infants, fine 
brown granules in the pelvis and calices, and occasionally a calculus as 
large as a small pea is found. They are usually composed of uric acid. 
Only once in over one thousand autopsies of which I have records, was 
a stone of any considerable size seen in an infant. In this case it was 
an inch in length and half an inch wide. It is surprising that these are 
so rare, when we consider how very frequently the minute calculi are 
met with. The probable explanation is, that the majority of them are 
dissolved or washed down into the bladder and passed per urethram 
because of the fluid diet of the first two years. The granular deposits 
are usually lodged in the pelvis of the kidney, and are generally seen 
upon both sides. With the larger collections there is often a slight 
catarrhal pyelitis. 

Symptoms. — The small deposits give no symptoms, and even quite 
large calculi may be found at autopsy where no indication of their pres- 
ence had existed during life, as in the case above mentioned. In some 
cases symptoms are produced which resemble those of renal calculi in 
the adult. In infants less definite symptoms are often passed over as 
merely intestinal colic. 

In well-marked cases in older children there is tenderness, pain local- 
ised over the affected kidney, or radiating to the bladder, the peri men m, 
and even the opposite kidney, and there may he irritation and retraction 



628 DISEASES OF THE URO-GENITAL SYSTEM. 

of the testicle. The urine may show, especially after exercise, a trace of 
blood; there may be the added symptoms of pyelitis, with some fever, 
Localised tenderness, ami the appearance in the urine of pus and epi- 
thelial cells from the pelvis of the kidney. 

Renal colic is produced when a stone of any considerable size passes 
from the kidney to the bladder. It is characterised by symptoms similar 
to those seen in the adult. There are sudden attacks of severe sickening 
pain in the loins, shooting down the thigh or to the testicle. There may 
be vomiting and even collapse. The urine is passed frequently, in small 
quantities, and contains blood. The symptoms quickly subside when 
the stone reaches the bladder. The calculus may sometimes become im- 
pacted in the ureter and give rise to hydronephrosis or pyonephrosis, 
which soon becomes pyelo-nephritis. 

The existence of small calculi may be suspected from the symptoms 
above mentioned; the diagnosis is made positive by the appearance of 
gravel in the urine. The use of the Rontgen rays is of service in recog- 
nising even small calculi. 

Treatment. — The only medical treatment consists in a fluid diet, the 
free use of alkaline mineral waters, and a sufficient quantity of some 
drug to render the urine alkaline. Such measures will relieve only the 
milder conditions. With larger calculi and more marked symptoms, a 
surgical operation should be considered and should be urged in propor- 
tion to the severity of the symptoms and the clearness of the diagnosis. 
If calculous pyelitis exists, it is certain sooner or later to lead to serious 
nephritis, and it is only a question of time when the kidney will be dis- 
abled. The same is true of hydronephrosis from the impaction of a cal- 
culus in the ureter. Aldibert has collected four cases of nephrectomy in 
children for renal calculi in which the kidney was healthy, with three 
recoveries and one death from shock. In nine cases of operation for 
calculous pyonephrosis, there were six recoveries and three deaths. The 
earlier the operation the greater the chances of success, because of the 
better condition of the other kidney. Although the continued use of 
water and the so-called solvents may relieve some of the symptoms, it 
is very questionable whether they do more. 

TRAUMATIC HYDRONEPHROSIS. 

In addition to the hydronephrosis which results from congenital mal- 
formations and from the impaction of calculi, a form is occasionally 
seen following severe injury to the kidney. The pathology of hydro- 
nephrosis in these cases is not well understood. After the early symp- 
toms of traumatism have subsided, there develops in from two weeks to 
two months a tumour in the region of the kidney, which may reach a 
considerable size and present all the ordinary characteristics of hydro- 



PERINEPHRITIS. 629 

nephrosis arising from other cause's. This tumour may disappear spon- 
taneously, or it may increase in size and demand surgical intervention 
for its cure. In seventeen cases which Ahlihert has collected there 
was only one of spontaneous recovery ; aspiration was done in 
cases, with six cures and one death; incision with or without nephrec- 
tomy was practised in nine cases, with seven recoveries and two deaths. 



PERINEPHRITIS. 

This consists in an inflammation in the cellular tissue surrounding 
the kidney, which may terminate in resolution or in suppuration. It is 
not of very uncommon occurrence, and is of importance chiefly from the 
frequency with which it is confounded with disease of the hip or spine. 
Perinephritis may be secondary to suppurative processes in the kidney 
itself, whether from calculi or tuberculous deposits, or it may be primary. 
In children the latter is the common form. Primary perinephritis is 
attributed to traumatism, cold, or exposure, or it may develop without 
assignable cause. It usually runs an acute or subacute course; very 
rarely it may be chronic. 

For the clinical picture of this disease I am chiefly indebted to a 
paper by Gibney, who has published a report of twenty-eight cases of 
primary perinephritis in children. The ages of these patients were be- 
tween one and a half and fifteen years, the majority being between three 
and six years. The two sides and the two sexes were about equally 
affected. About one-third of the cases were clearly traceable to trau- 
matism; in the others no adequate exciting cause could be discovered. 
The majority of the cases were referred to the hospital with the diag- 
nosis of hip- joint disease or caries of the spine. Resolution followed in 
twelve of these cases, and sixteen terminated in suppuration. 

When abscess forms, it usually burrows between the lumbar muscles 
and comes to the surface posteriorly near the middle of the ilio-costal 
space ; it may burrow forward between the abdominal muscles and point 
just above Poupart's ligament; very rarely it may follow the psoas 
muscle and appear at the upper and inner aspect of the thigh, like an 
ordinary psoas abscess; or it may open into the peritoneal cavity. 

Symptoms. — The onset of acute perinephritis may be quite abrupt, 
with chill, fever, and localised pain; or it may be gradual, with stiffness 
of the spine, lameness referred to the hip, and deformity due to contrac- 
tion of the flexors of the thigh. The pain is usually felt in the loin, but 
may be referred to the groin, to the inner side of the thigh, or to 1 he 
knee. It is often severe, and increased by using the limb. It is in most 
cases accompanied by localised tenderness in the neighbourhood of the 
kidney. There is lameness upon the affected side, which may come on 
gradually, being sometimes referred to the hip and sometimes to the 



630 DISEASES OV THE UROGENITAL SYSTEM. 

spine. These symptoms often develop slowly in the course of two or 
three weeks. They are usually accompanied by a slight elevation of tem- 
perature. In the most acute cases the temperature is high (102° to L04° 
P.), and prostration severe. 

As the disease progresses, fever is a constant symptom, the tempera- 
ture usually varying between 101° and 103° F. There is in most cases 
increasing deformity, and finally the patient may be unable to walk at 
all. On examination at the height of the disease, there is found in a 
typical ease a deviation of the spine with the concavity toward the af- 
fected side ; the thigh may be held flexed to a right angle ; passive exten- 
sion is resisted and causes pain, although all the other movements at the 
hip joint are normal. In the lumbar region there is tenderness, and 
there may be an area of infiltration filling the ilio-costal space. At first 
this is only appreciable by percussion, but later a distinct tumour is 
present. In addition to the tumour in the usual region, there is some- 
times one at the upper and inner aspect of the thigh, owing to a bur- 
rowing of pus, and the sacs may communicate. 

Lameness, pain, deformity, and fever sometimes exist for two or 
three weeks before any tumour can be made out. The constitutional 
symptoms are often severe. The size of the abscess is sometimes very 
great. In one case I saw it extend from the spine to the median 
line in front, and from the crest of the ilium nearly to the free border 
of the ribs. The amount of pus varies from a few ounces to two or 
three pints. Urinary symptoms are sometimes wanting; at other times 
there is increased frequency of micturition, accompanied by pain from 
an irritation referred to the bladder. The urine may contain pus from a 
complicating pyelitis. In only one of Gibney's cases was this present. 
It developed in the fourth week, and the case recovered. 

The duration of the disease in the acute cases varies from three to 
eight weeks; in the subacute it may be five or six months. When sup- 
puration occurs the symptoms subside quite rapidly after the pus has 
been evacuated, and recovery is complete. When resolution takes place, 
there is a gradual subsidence of the symptoms, and often some stiffness 
of the thigh, with slight lameness for several months. In the series of 
cases above referred to, sixty-five per cent recovered completely in three 
months. 

Diagnosis. — In many cases a diagnosis of hip-joint disease is made, 
but that disease develops more insidiously, is very much more chronic, 
and rarely produces so great deformity in a year as is often seen in peri- 
nephritis in two or three weeks; abscess is infrequent during the first 
year of the disease. In perinephritis, on the other hand, we have a 
tolerably acute onset, sometimes with chill, fever, marked lameness, and 
deformity, developing in two or three weeks; abscess often forms in 
a month, and complete and permanent recovery usually follows after a 



MALFORMATIONS OF THE GENITAL ORGANS. 631 

• 
iV\\ months at most; the deformity is due solely to flexion of the 
thigh; all other movements at the hip may be free, and joint tenderness 

is absent. Psoas abscess from Poll's disease may cause deformity, tu- 
mour, and lameness similar to that seen in perinephritis, hut on examina- 
tion there is found the angular prominence and other Bigns of disease 
of the lumbar vertebra 1 . In eases of doubt the tuberculin test may give 
important aid in diagnosis. 

Prognosis. — Primary perinephritis in children almost invariably ter- 
minates in complete recovery. Of the twenty-eight eases referred to, 
and eight subsequently observed by Gibney, all recovered perfectly. The 
only condition likely to prove fatal is rupture of the abscess into the 
peritoneal cavity. 

Treatment. — The patient should be put to bed and kept as quiet as 
possible throughout the attack. In the early stage, hot fomentations or 
an ice-bag should be applied over the affected side; heat is generally to 
be preferred. Abscesses should be opened early, to prevent burrowing 
and the danger of a possible rupture into the peritoneal cavity. 



DISEASES OF THE GENITAL ORGANS. 

MALFORMATIONS. 

Adherent Prepuce. — This condition is sometimes called false phi- 
mosis. It is so constantly present that it can hardly be regarded as a 
malformation. It is, however, a condition needing attention in even- 
male infant. The prepuce should be forcibly retracted so as to expose 
the glans completely. The smegma should then be washed away, the 
glans covered with a drop of oil, and the skin drawn forward. This 
should be repeated daily until there is no disposition to a recurrence of 
the adhesions. 

Phimosis. — This is such a narrowing of the prepuce that it can not 
be retracted, over the glans. The degree of phimosis varies greatly. In 
very rare cases there is no preputial opening. In other cases the orifice 
is so small that no part of the glans can be exposed, and there is obstruc- 
tion to the outflow of urine; but usually a small part of the glans can be 
seen. Phimosis may be complicated by an elongated prepuce (hyper- 
trophic phimosis), and the elongation may exist without any narrowing 
of the orifice, although this is usually present to some degree. 

The presence of phimosis makes cleanliness impossible in many ci 
and want of cleanliness leads to infection and to balanitis. This is quite 
frequent, even in infants. It may be complicated by urethritis, and even 



632 DISEASES OF THE (JRO-GENITAL SYSTEM. 

• 
by cystitis. Another consequence of the straining induced by phimosis 

is hernia, which may he oil her inguinal or umhilical. To cure the 
hernia is often impossible, unless the phimosis is relieved. Reflex symp- 
toms may come from preputial adhesions as well as from phimosis. The 
hyperaesthetic condition and the resulting pruritus cause frequent pria- 
pism, and are among the common causes of masturbation. Phimosis may 
produce other nervous symptoms, such as insomnia, night terrors, etc. 
It often causes frequent micturition, dysuria, and, in fact, most of the 
symptoms of stone in the bladder. It sometimes leads to vesical spasm 
and retention of urine, but more frequently to nocturnal incontinence. 

The list of reflex phenomena which have been ascribed to phimosis 
is a long one, and includes most of the functional nervous diseases of 
childhood. There has been in the past a disposition on the part of some 
to attribute nearly all the nervous disturbances of boyhood to phimosis, 
and an exaggerated importance has certainly been attached to this con- 
dition. Still, in a delicate, anaemic child with unstable nervous centres, 
phimosis is capable of giving rise to nervous symptoms of a serious char- 
acter. It is an important etiological factor in many neuroses, and one 
which should not be overlooked. On the other hand, a very marked degree 
of phimosis often exists in healthy children without producing any symp- 
toms whatever. 

Treatment. — Every case of phimosis should receive attention in in- 
fancy. Often very little treatment is needed; but trouble is likely to 
come sooner or later if it is neglected. When there is a very long prepuce 
with phimosis, the operation of circumcision should in my opinion be 
done, even when the degree of phimosis is slight. Many cases of phimosis 
in which the prepuce is not long can be relieved by stretching. If no part 
of the glans can be exposed, the simplest plan is to slit up the dorsum 
of the prepuce with a pair of scissors and forcibly break up the adhesions. 
The corners of the flaps thus made can then be snipped off and one stitch 
inserted on either side. In the case of obscure nervous symptoms in older 
boys,. the condition of the prepuce should be examined and the same rules 
of treatment applied. In cases of hernia, or prolapsus ani, when phimosis 
is present it should be relieved. 

Hypospadias. — In this condition the urethra is not continued to the 
tip of the penis, but opens on the inferior surface some distance back, 
being represented in front of this only by a shallow furrow. In more 
severe cases there is a deep fissure which divides the scrotum, and some- 
times even the perinaeum. Into this fissure the urethra opens. This is a 
condition likely to be mistaken for that of hermaphrodism, especially 
as the testicles are frequently in the abdominal cavity. 

Epispadias. — This is a condition in which the urethra opens on the 
dorsal surface of the penis. It is much less frequent than hypospadias. 
There may be simply a division of the glans, or the fissure may extend 



MALFORMATIONS OF THE GENITAL ORGANS 633 

the whole length of the organ and be complicated by exstrophy of the 

bladder. 

Exstrophy of the Bladder. — In the complete form there is a median 
fissure from the umbilicus to the tip of the penis. It includes the an- 
terior abdominal wall, the pelvic bones, and the urethra. The bon< 
entirely separated at the symphysis, or connected behind the bladder by 
a fibrous band. The hypogastric region is occupied by a red, mucous 
surface, slightly corrugated, which is all there is of the bladder. In the 
lower lateral portions of the red mucous membrane two slightly rounded 
elevations are seen, from which urine oozes. These are the openings of 
the ureters. The penis is short, and presents a shallow furrow on its 
dorsal surface. The testes are often in the abdominal cavity. 

An analogous deformity is sometimes seen in girls. There is a division 
of the clitoris and the labia minora and majora. The fissure may be so 
deep as to reach nearly to the anus. The vagina is usually absent. The 
rectum may open into the prolapsed bladder. 

All these deformities are compatible with long life. In most of them 
the individual is incapable of procreation. In exstrophy of the bladder, 
whether complete or partial, patients are a nuisance to themselves and to 
all about them. It is almost impossible to prevent the clothing from 
being soaked with urine, which gives everything connected with the 
patient a strong ammoniacal odour. The skin is often excoriated. Op- 
eration for the relief of these cases should, I think, always be undertaken. 
The operation to be recommended is the transplantation of the ureters 
into some part of the large intestine, usually the rectum. The results 
are often most surprising. The rectum soon becomes tolerant of the 
urine, holds it for hours without difficulty and evacuates it without dis- 
comfort. Ascending infection of the kidney seldom occurs. 

Undescended Testicle — Cryptorchidism. — In foetal life the testes are 
situated in the abdominal cavity below the kidneys. They usually descend 
into the scrotum during the ninth month, but in children born at term 
the testicles may be in the inguinal canal, or even in the abdomen. The 
former condition is quite frequent, being present in fully ten per cent of 
all male children. In most of these the descent takes place without dif- 
ficulty during the first weeks of life, and causes no symptoms. In others 
the condition may persist. Spontaneous descent may take place at any 
time before puberty, the chances, however, steadily lessening as age ad- 
vances. When in the inguinal canal, on account of its exposed situation, 
the testicle may be injured, or become painful and tender as puberty 
approaches. In any abnormal position it probably will not develop prop- 
erly, and may remain without function, but interference with the devel- 
opment of the body is rare. Hernia is a frequent complication. 

When in the inguinal canal, descent of the testicle may sometimes be 
facilitated by manipulation. If the condition is unilateral, operation is 



634 DISEASES OF 1HK URO-GENITAL SYSTEM. 

unnecessary except for relief of pain. If it is double, operation should 
be performed before puberty, preferably in the eleventh or twelfth year. 
Transplantation into the scrotum is at this time simple, and usually suc- 
cessful. Should pain be persistent, and transplantation impossible, the 
testicle may be replaced in the abdominal cavity. Removal is indicated 
only when degeneration has taken place. 

With the exceptions already mentioned, deformities of the female 
genitals belong rather to gynaecology than to paediatrics, since they are 
chiefly of the internal organs, and do not usually give symptoms before 
puberty. 

DISEASES OF THE MALE GENITALS. 

Balanitis. — Balanitis, or inflammation of the prepuce, is one of the 
results of phimosis. It may follow decomposition of the smegma, infec- 
tion of the mucous membrane, injury, or masturbation. The parts are 
swollen, oedematous, red, painful, and sometimes bathed in pus. Re- 
traction of the prepuce is impossible. Under proper treatment the in- 
flammation usually subsides in two or three days, but there may be some 
discharge for a considerable time. Abscess may follow, and even gan- 
grene of the prepuce. The most severe cases are likely to be complicated 
by anterior urethritis. I have frequently seen erysipelas start from 
balanitis, and occasionally diphtheria occurs here. 

The object of treatment is to remove the irritating and infectious 
material lodged beneath the foreskin. This may be quite difficult. It is 
best accomplished by syringing with a 1-5,000 bichloride solution, and 
the constant application of a wet antiseptic dressing. Ice is often useful 
when the oedema is great. It is sometimes necessary to slit up the 
prepuce before the parts can be thoroughly cleansed, and in severe cases 
this is often the quickest method of cure. Circumcision should not be 
done during an attack. 

Urethritis. — This, like the same disease in females, may be simple 
or specific. Both forms are less frequent in little boys than in the other 
sex. In simple urethritis the inflammation usually affects only the an- 
terior part of the canal, the fossa navicularis. There is a slight discharge 
of pus, and sometimes pain on micturition. The most frequent cause 
is want of cleanliness. 

Gonorrhceal inflammation is more common. This occurs even in in- 
fants, but most of the cases are in those over seven years old. The usual 
cause is direct contagion. The symptoms are more severe than in the 
simple form, and resemble the same disease in the adult, with the ex- 
ception that constitutional symptoms are usually absent. A microscopical 
examination of the discharge is the only positive means of diagnosis 
between the two varieties. In these cases it reveals the gonococcus in 
great numbers. Conjunctivitis and arthritis are seen as complications, 



DISEASES OF THE MALE GENITALS. 635 

jusi as in the female. Orchitis is very rare, but balanitis and bubo are 
not infrequent. Poynter has reported a ease in a boy of three years, who, 
when five years old, required treatment for a urethral stricture. Jl« 
infected by a nurse. 

The first thing in the treatment is always to keep the parts covered, 
otherwise the infection is almost certain to be carried by the hands to 
other mucous membranes, usually the conjunctiva. In other respects 
the treatment is the same as in the adult. 

Hydrocele. — Hydrocele consists in an accumulation of serum in some 
part of the serous pouch brought down by the testicle in its descent. In 
infants it is usually due to the imperfect closure of this pouch at some 
point, where a fluid accumulation occurs. Four varieties of hydrocele 
are met with in young children: 

1. Congenital Hydrocele. — In this the condition is a congenital one, 
although the tumour is not necessarily present at birth. The tunica vagi- 
nalis communicates with the' general peritoneal cavity. There is present 
an elongated tumour, extending from the bottom of the scrotum through- 
out the whole length of the cord. The tumour is reducible, sometimes 
spontaneously by position, sometimes, when the opening is smaller, only 
by pressure. It reduces slowly, without gurgling, never going back en 
masse like a hernia. The tumour is translucent, and is flat on percussion. 
The testicle is above and posterior, and usually indistinctly felt. Con- 
genital hydrocele may be complicated by hernia. 

2. Hydrocele of the Tunica Vaginalis with the Canal Closed. — In 
this form the accumulation of fluid is in the scrotum, communication 
with the peritoneal cavity having been entirely cut off by the complete 
obliteration of this pouch in the canal in the normal way. This is one of 
the most frequent forms. It gives rise to an oval or pear-shaped tumour, 
quite tense and firm, usually about two inches in length. The cord is 
distinctly felt above it, the testicle is behind and somewhat above it, and 
not always felt very distinctly. This variety gives translucency and the 
usual elastic feeling of a hydrocele. 

3. Hydrocele of the Cord. — This is one of the rare forms. The 
serous pouch which accompanies the spermatic cord is open above, and 
communicates with the peritoneal cavity; but below it is closed. The 
scrotum is normal, and the testicle is in its usual position. The tumour 
is small, elongated, and reducible, and entirely above the scrotum. Usu- 
ally it stops at some point in the inguinal canal. This hydrocele also 
may be complicated by hernia. The diagnostic points are the same as 
in the form first mentioned. 

4. Encysted Hydrocele of the Cord. — The peritoneal pouch of the 
cord in this variety is closed for some distance above, and again below, 
but somewhere in its course it is open, and here the fluid accumulates in 
the form of a cyst. When small it resembles an undescended testicle; 



636 DISEASES OF THE URO-GENITAL SYSTEM. 

but on examination this organ is found below and in its normal position. 
When in the canal, it is often mistaken for a lymph gland, sometimes 
for a small hernia. The tumour is usually about the size of an almond. 
It is elastic and irreducible, and translucent like the other varieties. 

Treatment of Hydrocele. — In the congenital form the application of 
a truss will sometimes cause obliteration of the canal, so as to shut off 
the hydrocele sac from the general peritoneal cavity. It is subsequently 
managed like an ordinary hydrocele of the tunica vaginalis. In infants 
and young children it is rare that active operative measures are called 
for in any variety of hydrocele, as these usually tend to disappear spon- 
taneously in the course of a few months. Iodine may be applied locally 
over a hydrocele of the cord, but should not be applied to the scrotum. 
Some cases are cured by a simple puncture with a needle, allowing the 
fluid to drain off into the cellular tissue of the scrotum from which it 
is absorbed; others by a single aspiration with a hypodermic syringe. 
It is seldom necessary to resort to the injection of irritants like iodine 
or carbolic acid, but they may be used if the fluid returns after repeated 
aspirations. 

DISEASES OF THE FEMALE GENITALS. 
Vaginitis. 

This is a catarrhal inflammation usually affecting only the vaginal 
mucous membrane, but may involve the urethra, bladder, and, in older 
girls, the lining membrane of the uterus, the tubes, and even the peri- 
tonaeum. It may be either simple or specific (gonorrhceal) ; the purulent 
form is almost invariably specific. 

Simple Vaginal Catarrh. — This may be seen at any age, even in in- 
fancy, but is most frequent after the second year. It oceurs especially 
in girls suffering from malnutrition and anaemia, and whose personal 
cleanliness is neglected. It may follow any of the infectious diseases, 
particularly measles. It sometimes complicates varicella with a local 
lesion in the vagina. It may be traumatic, as from attempted rape or 
the introduction of foreign bodies. Other causes are pinworms and 
scabies. It is sometimes the cause, sometimes the result of masturbation. 

Symptoms. — The disease generally begins as a subacute catarrhal in- 
flammation, the discharge being the first, and in mild cases the only 
symptom. It is of a white or yellowish white colour and not very abun- 
dant. If the parts are not kept clean the odour of the discharge is quite 
foul. In severe cases the discharge is abundant, and may excoriate the 
skin of the labia and thighs. The mucous membrane is swollen and red, 
but there is only a moderate secretion. Microscopical examination of 
the discharge shows bacteria in large numbers and of many varieties, but 
they are chiefly the ordinary cocci. With proper treatment and in chil- 
dren who are in good general condition, the disease usually lasts from 



DISEASES OF THE FEMALE GENITALS. 637 

one to three weeks; or, under unfavourable conditions, there may be a 
persistent leucorrlueal discharge for a longer time. 

Gonococcus Vaginitis. — So far from being pare, as was once thought, 
this disease has been shown by recent observations to be exceedingly com- 
mon among girls of all ages, even young infants. It is especially in 
hospitals and other institutions that it is seen, and here it must be con- 
sidered one of the most frequent and most troublesome of house infec- 
tions. Routine microscopical examinations which I have had made 
of the vaginal discharges of children in various institutions usually 
revealed the existence of gonococcus vaginitis, often in a mild form, 
in from two to ten per cent of the inmates. Epidemics in institutions 
are exceedingly common and very difficult to control. Only one who has 
experienced such epidemics can appreciate what a scourge vaginitis may 
become. No less than four such epidemics were observed in the Babies' 
Hospital between the years 1899 and 1904. During this period 273 
cases were observed in this institution. 1 Gonococcus vaginitis often exists 
in day-nurseries or homes for foundlings, as well as in general hospitals 
and asylums for older children. In out-patient practice, and among the 
poor in tenements, cases are constantly seen, and even among the well- 
to-do this disease is by no means rare. From the manner in which it is 
contracted, it should not, in young children, be considered a venereal 
disease. 

In institutions, gonococcus vaginitis can generally be traced to some 
child admitted with an acute form of the disease. Before the condition 
is recognised and the patient quarantined, an entire ward or dormitory 
may be infected, and a local epidemic may be the result, and once well 
under way this may last for months. 

In infants and young children the disease is seldom acquired by sex- 
ual contact, but most frequently through the medium of napkins. Other 
possible means of infection are towels, sponges, wash-cloths, undercloth- 
ing, bed-linen, thermometers, syringes, bath-tubs, bath water, or the 
hands of the nurse. Even when the most careful attention has been 
given to these matters, I have frequently seen ward epidemics continue 
unabated. Atmospheric infection seems unlikely. The most probable 
explanation under these circumstances is that the disease is spread by 
nurses in washing, feeding, dressing, or bathing children, but especially 
in the changing of napkins. In many cases it was found impossible to 
check epidemics until both the patients and their attendants were quar- 
antined. 

In girls from six to twelve years old other means of contagion must 
be considered. This may be by direct contact, manual or sexual, or sleep- 

1 See author's article on Gonococcus Infections in Institutions, New York Medical 
Journal, March, 1905. 



638 DISEASES OF THE UROGENITAL SYSTEM. 

ing with parents or others who may have the disease. Potl found in 

ninety per eent of his cases that the mother had a Leucorrhoeal discharge. 
The mode of contagion may he difficuH to trace, but this fart should cast 
no doubt upon the diagnosis. 

Symptoms. — In infants and young children, in the mild eases, the 
disease is limited to the mucous membrane of the vagina. There is a 
moderate yellow discharge which, by microscopical examination, contains 
pus cells and gonococci. There is little redness and no symptoms of dis- 
comfort. In more severe cases the discharge is copious, often thick and 
of a yellow or yellowish-green colour. It may be tinged with blood from 
slight erosions. It often causes excoriation of the labia or thighs. In 
some cases the urethra is involved, causing frequent, painful micturition. 
The inflammation may extend to the bladder, but seldom or never at 
this age to the mucous membrane of the uterus. Occasionally the mucous 
membrane of the rectum is involved. The symptoms are chiefly local, 
but there may be a slight rise of temperature to 100° or 101° F. during 
the period of most acute inflammation. 

In girls past the age of six or seven years, the symptoms resemble 
those of the adult : copious secretion, the formation of crusts on the labia, 
frequent, painful micturition from involvement of the bladder and 
urethra, and difficulty in locomotion. There may be slight fever and 
general malaise. The inflammation may extend to the lining membrane 
of the uterus and, through the Fallopian tubes, to the pelvic peritonaeum. 
Sanger has reported such a case in a child of three years. The endome- 
tritis may be demonstrated by the use of a small speculum, by which the 
discharge may be seen coming from the cervix. Swelling, and very rarely 
suppuration, of the inguinal glands may take place. 

A positive diagnosis between simple and gonococcus vaginitis can be 
made with certainty only by a microscopical examination of the discharge, 
though in default of such examination an abundant purulent catarrh 
may be assumed to be due to the gonococcus. In simple catarrh the dis- 
charge is made up of epithelial and pus cells, with quite a wide variety 
of bacterial forms, chiefly cocci and bacilli, occasionally a few diplococci. 
In gonococcus vaginitis the gonococci are found in large numbers, and 
are usually the only bacteria present. To be diagnostic, they should 
be demonstrated within the pus cells as well as outside them. The gono- 
coccus decolourises when stained by Gram's method, which fact distin- 
guishes it from the other organisms likely to be present in the vagina. 
The staining is quite as diagnostic as the cultural characteristics of this 
organism. Cases of vaginitis are to be regarded as suspicious if pus is 
found and few organisms are detected ; in such conditions subsequent ex- 
amination usually reveals the gonococcus. In my hospital experience the 
gonococcus cases have outnumbered the simple purulent forms, fully ten 
to one. 



DISEASES OF THE FEMALE GENITALS. 639 

In infants, when the amounl of discharge is small and likely to 
be overlooked, it is an advantage to apply between the labia a fold of 
gauze upon which the yellow stain of a jm rulciit discharge is readily 
noticed. 

Gonococcus Vaginitis may be complicated by conjunctivitis, arthritis, 
endo- or pericarditis, peritonitis, and proctitis. Conjunctivitis is the 
most frequent, the infection usually being carried by the hands. Gono- 
coccus arthritis is not uncommon even in young infants. It is usually a 
multiple arthritis, with the constitutional symptoms of pyaemia. The 
wrist, ankle, knee and elbow, and small joints of the fingers and toes are 
most frequently involved. These cases are considered more fully in the 
chapter on Acute Arthritis in Infants. 

The diagnosis in all the complicating conditions is based upon the 
presence of the gonococcus. 

Prophylaxis. — The highly contagious character of gonococcus vagi- 
nitis makes it imperative that such cases should not be received into the 
same ward or dormitory with other children. Only in this way can 
house epidemics be prevented. Cases which are mild should be excluded, 
as well as those which are severe. The only effective measure is to make 
the microscopical examination of vaginal discharges of children admitted 
to an institution as much a matter of routine as the taking of throat 
cultures if there is a tonsillar exudate. Cases showing the gonococcus 
should be quarantined or excluded. When there are a great many ad- 
missions every month, a case occasionally escapes detection. The rule 
which we have followed in the Babies' Hospital has been to make not 
only an examination on admission, but routine examinations of all pa- 
tients at stated intervals, always once and sometimes twice a week. Only 
by this means has it at times been possible to eradicate the disease. 

The attendants, both day and night nurses, as well as the children, 
should be quarantined. Napkins, underclothing, and sheets from the 
beds of infected children, also towels and wash-cloths, should not go 
into the common laundry, but should be first soaked in a strong solution 
of carbolic acid, and afterward boiled. In wards or institutions where 
cases have occurred washable napkins should be discontinued and old 
muslin and absorbent cotton used in their place. These are to be de- 
stroyed after using. All articles connected with the children's toilet, also 
syringes, thermometers, etc., should be carefully disinfected. But often 
this is not enough. Separate articles should be furnished for each child. 
The organism is one that is fairly easy to kill, and if proper precautions 
are taken epidemics may be prevented. The essential measure is a prompt 
recognition and isolation of the first case in the hospital. Quarantine 
should continue not only until the catarrhal inflammation has subsided 
and the organism has disappeared, as shown by a single negative micro- 
scopical examination, but for a considerable time longer, since a Blight 



640 DISEASES OF THE URO-GENITAL SYSTEM. 

discharge containing a lew organisms may remain for weeks after the 
case is considered cured. Relapses are very frequent. 

Treatment— Cases of simple vaginal catarrh should be irrigated twice 
daily with B warm saturated solution of boric acid or 1 to 5,000 bichlo- 
ride. Cleanliness should be secured by frequent bathing and the skin 
protected by ointments. In more severe cases, astringent injections, such 
as sulphate of zinc and tannic acid (of each one drachm to a pint 
of water) should be used, or protargol applied in solutions of from one 
to live per cent strength. The general health should be built up by 
iron, cod-liver oil, and other tonics. 

In gonococcus vaginitis more energetic treatment is necessary. Every 
child should wear a napkin, to prevent carrying the infection to the eyes 
by means of the hands. Irrigations should be used at least twice a day, 
and stronger antiseptics employed than in the simple cases. The best 
are protargol, in solutions from one to ten per cent strength, and argyrol, 
in solutions from five to twenty-five per cent strength. Applications 
should be made with a cotton swab; the same substances may be used in 
the form of suppositories, or the vagina may be packed with gauze wet 
in these solutions. The closest attention to cleanliness is required in all 
cases. The course of the disease is very tedious; many weeks, and often 
months, may be required for a cure. On the whole, treatment is very 
unsatisfactory on account of the difficulties in the way of making thor- 
ough local applications. When the disease involves the bladder and 
urethra, the same general measures as in adults are indicated. 

The precise place and value of vaccines in the treatment of gonococcus 
vaginitis is undetermined, reported results with this method being far 
from uniform. When practicable I believe that they should be given a 
trial in all chronic or specially resistent cases. I have personally seen 
a few brilliant results from their use. I have generally employed stock 
vaccines made from many strains of the gonococcus. Dosage is still a 
matter of much uncertainty. Fifty to seventy-five millions may be used 
every four or five days until five or six doses have been given. I have 
seen no unfavourable symptoms in any case. 

Gangrenous Vulvitis (Noma). 

This is the same process as that seen in the mouth and known as 
cancrum oris. It usually follows one of the infectious diseases, most 
frequently measles, occurring in patients whose general vitality has been 
greatly reduced. There is first noticed a tense, brawny induration, the 
skin being shiny and swollen over a circumscribed area. In the centre 
of this there soon appears, usually upon one of the labia majora, a dark, 
circumscribed spot. Day by day the gangrenous area advances, preceded 
by the induration. It may involve the whole labium, extending even to 
the mons veneris and the perinaeum. These cases are generally fatal. 



ENURESIS. 641 

If recovery takes place, it is with considerable deformity of the parts in 
consequence of the extensive sloughing and cicatrisation. As sequelae, 
there may be fistulas, stenosis, or atresia of the vagina. The only radical 
treatment is early excision, and the application of the actual cautery, 
carbolic or nitric acid. 

CHAPTER IV. 
DISEASES OF THE BLADDER. 

ENURESIS. 

(Incontinence of Urine; Bed-wetting.) 

Enuresis may be due to some malformation of the genital tract, such 
as an abnormal opening of the bladder into the vagina, to extroversion 
of the bladder, or to the persistence of the urachus; in the latter case 
the urine is discharged from the umbilicus. It also occurs in organic 
diseases of the central nervous system, such as idiocy, cerebral palsy, 
acute meningitis, tumours of the brain, certain forms of myelitis, and 
in injuries of the cord. In many of these conditions there is associated 
incontinence of faeces. Both of the groups of cases mentioned are quite 
distinct from the ordinary form of incontinence of urine which is seen 
in childhood. The latter is to be regarded as a neurosis, and is the 
only variety which will be considered here. 

It is in many cases possible to teach infants to control the evacuation 
of the bladder before the end of the first year ; usually, however, control 
is not acquired even during waking hours until some time during the 
second year, and in some healthy infants not before the end of the second 
year. The time depends very much upon the training. If a child during 
its third year can not control the evacuation of the bladder during its 
waking hours, incontinence may be said to exist. 

Etiology. — Incontinence of urine may be due to a continuance of the 
infantile condition, to anything which increases the irritability of the 
spinal centre, or which interferes with the cerebral control over this 
centre, or to anything which increases the irritability of the terminal 
filaments of the vesical nerves or of those in the neighbourhood. The 
causes of incontinence thus may be in the central nervous system, in the 
urine, in the bladder, or in any of the adjacent organs. 

The causes relating to the central nervous system are in the main 
those of the other neuroses of childhood ; these are anaemia, malnutrition, 
an inherited nervous constitution, or a condition of extreme nervousness 
or neurasthenia, the result of the child's surroundings. In such cases 
incontinence is often associated with chorea, epilepsy, hysteria, headaches, 
neuralgia, and other nervous symptoms. In these conditions there may 
be not only an increased irritability of the nerve centres, but also of the 
42 



542 DISEASES OF THE URO-GENITAL SYSTEM. 

peripheral nerves, accompanied by loss of tone of the vesical sphincter. 
A similar condition may exist with almost any form of acute illness, 
usually, however, being only temporary. 

Incontinence may be caused either by a highly acid, concentrated urine 
when an [nsnfBcienl amount of fluid is taken, or by the opposite condi- 
tion, where, owing to the drinking of a large quantity of water, often 
only a matter of habit, the amount of urine is very greatly increased and 
passed at frequent intervals. 

In the bladder itself, cystitis and vesical calculus, although infre- 
quent, should not he overlooked as possible causes. In a few cases, where 
incontinence has existed a long time, the bladder becomes so contracted 
that it will hold only an ounce or two of urine. This condition, although 
not the primary cause of enuresis, may be enough to continue it. 

Local irritation in the neighbouring organs may be due to adherent 
prepuce, balanitis, phimosis, or to a narrow meatus. All of these condi- 
tions are frequently associated with incontinence. Rectal irritation may 
be due to pinworms, anal fissure, or rectal polypus; and vaginal irrita- 
tion to vulvo-vaginitis or adherent clitoris; but these are rarely the only 
cause. Often we have incontinence as the result of a combination of sev- 
eral causes, no one of which alone would have been sufficient to produce 
it. Thus, in a healthy child phimosis may give rise to no symptoms, while 
in one who is anaemic or neurasthenic it may produce enough local irrita- 
tion to cause incontinence. In many cases heredity seems to be a 
factor of some importance, parents often having suffered in their child- 
hood from the same condition; quite frequently two and sometimes even 
three children in the same family are affected. In many cases the con- 
dition seems to be mainly the result of habit, and in all cases habit is 
a potent factor in continuing the incontinence, sometimes after the orig- 
inal exciting cause has been removed. Frequently no adequate cause 
can be found. Both sexes are about equally liable to enuresis, and it 
may be seen in all ages up to puberty. 

Symptoms. — Enuresis may be nocturnal or diurnal, or both. Of 184 
cases, 73 were nocturnal, 9 diurnal, and 102 were both nocturnal and 
diurnal. Cases differ greatly in severity. Incontinence may be habitual, 
occurring every night, often several times during the night, and fre- 
quently during the day ; or it may be only occasional under the influence 
of some special exciting cause, when it continues a few days or weeks 
until the cause is removed. In a considerable number of cases, the condi- 
tion lasts from infancy until the sixth or seventh year. It may even con- 
tinue until puberty ; but it generally ceases at that period, unless its cause 
is mechanical or depends upon some organic disease of the brain or cord. 
In ordinary enuresis there is never dribbling of the urine, but usually a 
contraction of the walls of the bladder follows almost immediately upon 
the desire before the patient can make his wants known or reach a con- 



ENURESIS. 643 

venient place for micturition. At night the same thing may occur with- 
out wakening the child, the contraction being of purely reflex origin. 

Prognosis. — The condition is usually hopeless when it depends upon 
organic disease of the brain and cord; also in. cases due to malformation, 
unless these are amenable to surgical treatment. In the ordinary cases 
seen, the prognosis depends upon the age of the child, the duration of the 
symptom, and the nature of the exciting cause. In children of from 
three to five years a cure can in many cases be accomplished with proper 
management. Those who are older are much less amenable to treatment, 
especially if the condition has persisted since infancy; but if the incon- 
tinence has begun after seven or eight years of age and lasted a few weeks 
or months, the outlook is much more encouraging. When some cause can 
be discovered which can be removed, the prognosis is better than if none 
can be found. There are, however, some cases in which no other cause 
than habit can be discovered which resist all treatment, the condition 
finally ceasing spontaneously at or a little before puberty; in very few 
does it continue beyond this period. 

Treatment. — The first indication is to remove the cause, when one 
can be found. If there are preputial adhesions, they should be broken 
up and irritating smegma removed. If phimosis is present, it should be 
relieved by stretching or circumcision. If stone in the bladder is sus- 
pected, as it should be when the incontinence is worse by day and ac- 
companied by straining and painful spasm of the bladder, the patient 
should be sounded for stone. Pinworms in the rectum should receive 
the appropriate treatment by injections. While the local conditions 
mentioned should always be attended to, the fact remains that few 
cases are cured simply by relieving them, except those due to vesical 
calculi. The explanation of this is that habit is a very important factor 
in keeping up incontinence where it has existed a long time. 

A concentrated urine of high acidity with deposits of uric acid is 
an indication for alkalies and the free use of all fluids, especially ^vater. 
On the other hand, when there is passed a large quantity of urine with 
low specific gravity, the amount of water and other fluids should be 
restricted. During the night water should be forbidden, and the amount 
given in the latter part of the day greatly reduced. In these cases the 
incontinence is often simply the result of the polyuria, which in turn 
depends upon polydipsia. 

In most cases the condition is a nervous habit, and usually associated 
with other habits which indicate an unstable or highly susceptible 
nervous system. It is therefore of the greatest importance that a proper 
general regime should be instituted and enforced. Care should be taken 
to secure for the child a simple, natural life, preferably in the country. 
There should be no overtaxing of the nervous system at home or in 
school. Every cause of unnatural excitement should be avoided. Early 



544 DISEASES OF THE DRO-OENTTAL SYSTEM. 

hours and plenty of Bleep must be insisted upon. Certain articles of 
diet are to be avoided, and coffee, tea, and beer should be absolutely pro- 
hibited. Sweets and all highly seasoned food should be very sparingly 
allowed, or not at all. Although it is believed by many that a diet into 
which meat enters largely is injurious, from personal experience I have 
not found the exclusion of meat to be of any advantage. The diet which 
edfl best is a simple one composed of milk, vegetables, fruits, meats, 
and cereals. With most patients who have nocturnal incontinence, it 
is well to allow fluids freely during the early part of the day, but little 
or none after 3 or 4 p.m., a dry supper being given just before retiring. 
The child should be taught to hold his water as long as possible during 
the day, to accustom the bladder to full distention. 

Measures directed toward improving the general muscular and 
nervous tone are of the greatest importance. It should be remembered 
that incontinence of urine is a neurosis, depending, like most neuroses of 
childhood, upon disturbed nutrition. Ansemia, chlorosis, malnutrition, 
indigestion, and constipation should each receive careful attention. Any 
local condition, such as adenoid growths of the pharynx, which might 
serve to increase the general nervous irritability, should be removed. 
Yet. very few cases are cured by such an operation. 

Moral treatment is also important. One should work upon the child's 
pride and use every possible means to strengthen his will. Punishments, 
whether corporal or otherwise, do little good, and with most children 
they are absolutely harmful. With children in whom incontinence is 
chiefly a matter of habit, I have often found rewards more efficacious 
than any other means of treatment. One shoulaT^rsTfind out what it 
is that the child desires most — a new doll, a bicycle — and allow him to 
have it if his bed is dry, taking it away if it is wet. A reward of five 
cents for every dry night sometimes works marvels. 

The measures described — removal of local causes, building up of the 
general health, institution of a proper regime, and mental and moral 
means — in a very considerable number of cases suffice for a cure. They 
generally constitute the most important part of the treatment. Drugs 
are useful as accessories, but alone seldom accomplish a cure, and, on 
the whole, are disappointing. Of those employed, belladonna is cer- 
tainly the most effective, but its administration should be continued for 
a long time. Atropine, either in solution or in tablet form, is the most 
convenient method of administration. For nocturnal incontinence, j^ott 
of a grain for each year of the child's age up to seven years is a suit- 
able initial dose. A child of five would thus be taking -^ of a grain. 
At first, a single dose should be given at bedtime; after a few days a 
second 1 dose may be given three or four hours earlier. To push the drug 
much further than this causes much discomfort and is of doubtful ad- 
vantage. After the condition is under control, the same dose should 



VESICAL SPASM. 645 

be continued for some time and then reduced, the atropine being given 
for at least two months in gradually diminishing doses after the incon- 
tinence lias ceased. This is very important if the cure is to he perma- 
nent, as there is a strong tendency to relapse. 

Strychnine may be added in cases not yielding to the atropine alone. 
It is particularly advantageous when there is diurnal as well as nocturnal 
incontinence, for under these conditions there is usually a lack of tone in 
the sphincter, as well as increased irritability in the mucous membrane 
of the bladder. The initial dose for a child of five years should be T V<r 
of a grain twice daily; this may be gradually increased to -fa of a grain 
three times a day; but there is rarely any advantage in pushing it fur- 
ther. Ergot is sometimes useful in conjunction with other drugs, but 
rarely gives relief when both strychnine and atropine have failed. Some 
obstinate cases are reported to have been relieved by faradism; the posi- 
tive pole is attached to a small electrode passed into the rectum and the 
negative pole applied over the bladder. The sitting should last for ten 
minutes, and be repeated three times a week. My own experience with 
this method of treatment has been disappointing. If there is reason to 
suspect a contracted bladder, as when the incontinence has lasted for 
years and the bladder will never hold more than an ounce or two of 
urine, cure is sometimes accomplished by daily distending the organ 
up to its normal capacity with warm water. A few obstinate cases in 
older boys which had resisted all other methods of treatment were cured 
in my clinic by the passage of sounds. 

Careful, intelligent, systematic training is a most valuable adjunct 
to all measures employed for the relief of this very annoying condition. 

VESICAL SPASM. 

This is quite a common condition, and often passes under the name 
of genital irritation. It is characterised by frequent, sometimes by diffi- 
cult and painful, micturition. It occurs in children of all ages, even in 
infants, but is especially frequent between the ages of two and five years. 
This symptom has already been referred to in connection with uric-acid 
infarctions in very young infants. 

The usual cause is the irritation of the bladder by a concentrated, 
highly acid urine. It often results from cold; it may accompany acute 
febrile processes, and is sometimes merely a symptom of nervous irrita- 
bility. The cause may thus be in the bladder or in the urine. It may be 
accompanied by enuresis, but usually occurs without it. It is sometimes 
symptomatic of disease in adjacent parts, as in the rectum or the pelvic 
peritonaeum, or it may be associated with inflammation of the vulva or 
urethra. It is also one of the symptoms of vesical calculus. 

The symptoms of vesical spasm are local only. The child passes 



040 DISEASES ov THE FRO-GENITAL SYSTEM. 

water very frequently, often several times an hour. The accompanying 
pain may be intense, not infrequently sufficient to cause the child to 
cry out. Often there is pain and se\ere vesical tenesmus with the pas- 
sage o( only a few drops of urine at a time, but blood is not present. If 
the condition depends upon the character of the urine, or is only an 
expression of an extreme vesical irritability, the symptoms are generally 
of short duration, possibly a day or two. If it depends upon vesical 
calculus, it may be intermittent. If it is associated with disease of the 
adjacent pelvic viscera, it is inconstant, and may continue for a con- 
siderable period, depending upon the nature of the cause. 

The treatment, in the ordinary cases, consists in the administration 
of an abundance of water, with alkaline diuretics, and either belladonna 
or hyoseyamus. The tinctures of these may be given in minim doses 
every two hours to a child of two years. 

If the cause is outside the bladder, it should receive appropriate 
treatment. 

VESICAL CALCULI. 

Vesical calculus is a very rare condition in children in New York. 
The nucleus of a calculus is usually a renal calculus which has passed 
the ureter, but has been prevented by its size from going farther. Stone 
in the bladder is extremely rare in infancy, probably owing to the fluid 
diet, but it is not infrequent in children from two to ten years of age. 
The most common variety of calculus at this time is the uric acid. 

The svmptoms in children are somewhat different from those in 
adults, and the condition is often overlooked. There is frequently pain 
upon micturition, especially at the close of the act, which may be felt 
at the end of the penis or in the perinaeum. There may be a sudden 
stoppage in the flow of urine. The straining often leads to rectal tenes- 
mus and even to prolapse. This complication is so frequent that, in a 
case of persistent prolapse, stone should always be suspected. Incon- 
tinence of urine is a prominent, and often the principal symptom; in 
many cases it is noticed only during the day. The urinary changes are 
not generally marked; ha?maturia is rare, and mucus and pus are in- 
frequent and in small quantity. The genital irritation may lead to the 
habit of masturbation. A stone of any considerable size may often be 
felt by a bimanual examination, one finger being placed in the rectum 
and the other hand above the pubes. This is easier in males than in 
females, but it is not very trustworthy, and not conclusive when it gives 
a negative result. A positive diagnosis is made only by exploring the 
bladder with a sound or by the Rontgen rav. 

The treatment of calculus is purely surgical. 




SECTION VII. 
DISEASES OF THE NERVOUS SYSTEM. 



CHAPTER I. 

INTRODUCTORY. 

The Weight of the Brain. — From ninety-eight observations made in 
the post-mortem room of the New York Infant Asylum, the following 
were the average weights noted: 

At three months 21 oz. (602 grammes). 

At six months 25}/ 2 " (712 " ). 

At twelve months 32^2 " (916 " ). 

At two years 35 "(990 " ). 

The following are the figures given by Boyd and Schafer: 



Age. 


Males. 


Females. 


At birth (full term) 


Ounces. 

ny 2 

173^ 

21 

27 

33 

39 

40 

46 

48 J^ 


Grammes. 

330 

500 

602 

776 

941 

1,110 

1,138 

1,301 

1,374 


Ounces. 

10 

16 

20 

26 

30 

35 

40 

40^ 

44 


Grammes. 

283 


Under three months 


450 


From three to six months 

From six to twelve months 

From one to two years 

From two to four years 


560 

727 
843 
990 


From four to seven years 

From seven to fourteen years 

From fourteen to twenty years 


1,135 
1,154 
1,244 



At birth the weight of the brain to that of the body is nearly 1:8. 
During infancy and childhood the following is the ratio, according to 
Bischoff : during the first year, 1:6; the second year, 1 : 14 ; the third 
year, 1 : 18 ; at the fourteenth year, 1 : 15 to 1 : 25 ; in adults, 1 : 43. 

The Spinal Cord. — The weight of the cord to the weight of the body 
at birth is 1 : 500 ; in adult life it is 1 : 1500. According to Kolliker, the 
spinal cord and the vertebral column are the same length until the end of 
the third month of foetal life, there being at this time no cauda equina. 
At the ninth month the lower end of the cord is opposite the third lum- 
bar vertebra ; in the adult it is opposite the first. 

Some Peculiarities in the Diseases of the Nervous System in Infancy 
and Childhood. — The relatively large size, the rapid growth, and the im- 

647 



(,ls DISEASES OF THE NERVOUS SYSTEM. 

maturity o( the brain and cord during early life, explain much that is 
peculiar to the nervous diseases of this period. 

At this time, apparently trivial causes are enough to produce quite 
profound nervous impressions, because of the instability of the nervous 
centres and the greater irritability of the motor, sensory, and vaso-motor 
nerves. These are conditions which are very much increased by all dis- 
turbances of nutrition. These disturbances may be manifold in character, 
but they lie at the root of very many of the neuroses of early life, e. g., 
extreme nervousness, disorders of sleep, stuttering, chorea, incontinence 
of urine, tetany, and convulsions. The great liability to convulsions 
depends not only upon the greater irritability of the peripheral nerves, 
but upon the instability of the nervous centres and the lack of inhibition 
over the motor ganglion cells of the spinal cord. The nervous centres are 
more easily exhausted than later in life. Prolonged or continuous over- 
strain from any cause whatsoever, frequently leads to headache and 
chorea, and sometimes even to epilepsy and insanity. 

Another peculiarity is the serious consequences which often follow 
reflex irritation, although this is rarely the only factor in the case. Con- 
ditions which in adult life produce almost no effect may in infancy be 
the cause of most alarming symptoms. As a few examples may be cited, 
reflex symptoms due to phimosis or to intestinal worms, convulsions from 
disturbances of digestion, nervous symptoms due to eye-strain, or to 
adenoid growths of the pharynx. In the production of some of these, 
especially attacks of convulsions, there are several factors, such as the 
great irritability of the peripheral nerves, the instability of the nervous 
centres — often a result of disturbed nutrition, as in rickets — and the lack 
of inhibitory action of the cortex of the brain. 

As a third point of importance may be mentioned the grave per- 
manent results which often follow relatively small organic lesions. A 
good illustration is seen in the lesions which produce cerebral birth-palsy. 
Here the damage is only in small part the immediate effect of the haemor- 
rhage, for this often is not great, but it is the interference with the devel- 
opment of certain parts of the cortex that makes this condition so serious, 

From what has been said, it follows that the hygiene of the nervous 
11 is of the utmost importance in infancy and childhood. It is 
essential for the healthy development of the nervous system that all stim- 
ulants should be avoided — not only tea, coffee, and alcohol, but undue 
and unnatural excitement, the effect of which in infancy is almost as 
serious. A normal development can take place only in the midst of quiet 
and peaceful surroundings, with plenty of time for rest and sleep. The 
conditions of modern life, especially in cities, are such that these laws 
are almost invariably violated, and the consequences of this are seen 
in the marked and steady increase in nervous diseases among children. 



CONVULSIONS. 649 

CHAPTER II. 
GENERAL AND FUNCTIONAL NERVOUS DISEASES. 

CONVULSIONS. 

All young children, but especially infants, are extremely prone to 
convulsive disorders, which are manifested clinically in great variety. In 
certain infants, particularly those who are rachitic, this susceptibility 
is greatly heightened. To this condition of extreme liability to con- 
vulsive attacks the term spasmophilia is frequently applied. The con- 
vulsive disorders of infancy are: (1) attacks of eclampsia or general 
convulsions, the type best known; (2) tetany with carpo-pedal spasm; 
(3) laryngismus stridulus or crowing attacks ; (4) the less typical, hold- 
ing-breath spells, which are apparently a minor form of a general con- 
vulsion. Besides these, there are seen in infants a great variety of at- 
tacks, which recur from time to time, over quite a long period frequently, 
of a very doubtful character, until finally they develop into one or other 
of the types just mentioned. All these convulsive disorders are closely 
related to one another and an alternation of type from time to time is 
common. The general etiology of these conditions is still obscure. Their 
association with rickets is certainly very close. There is also ground 
for believing that in many of these children there is a disturbed calcium 
metabolism. 

Under the head of convulsions are included attacks of acute transient 
nervous disturbance, characterised by involuntary rhythmical spasm of 
the muscles, either of the face, trunk, or extremities, or all of them, usu- 
ally accompanied by loss of consciousness. They may be regarded as 
" motor discharges " from the cortex of the brain. 

Etiology. — The principal predisposing causes are infancy, conditions 
affecting the nutrition of the brain, and hereditary influences. Of all 
these factors, the most important one is the instability of the nerve 
centres which is characteristic of infancy and is associated with the non- 
development of the voluntary centres of the cortex. The brain grows 
more during the first year than in all later life, and this rapidity of 
growth is in itself an important predisposing cause of functional derange- 
ment. After infancy, attacks of convulsions are much less frequent, and 
after seven years they are relatively rare. While convulsions occasionally 
occur in children previously healthy, the majority of attacks are in those 
in whom there is at least some disturbance of the nutrition of the brain — 
the cerebral instability of infancy being greatly exaggerated by such 
nutritive disorders. The most frequent one is rickets, which may be re- 
garded as altogether the most important predisposing cause of infantile 
convulsions. They are often one of the earliest symptoms of that dis- 



650 DISEASES OF THE NERVOUS SYSTEM 

ease, ami when convulsions incur in infancy without evident cause, 
rickets should always be looked for. Any disturbance of nutrition, such 
as is seen in status lymphaticus, syphilis, anaemia, malnutrition, and ex- 
haustion resulting from any acute disease, especially one of the digestive 
tract, may predispose to convulsions. Children who inherit from their 
parents a peculiarly nervous temperament are more liable to convulsions 
than are others. This predisposition is often seen in several members of 
the same family. The younger the child the greater the susceptibility. 
Females are rather more frequently affected than males. 

The exciting causes include a wide variety of pathological conditions, 
among which disturbances of digestion take the first place. Where the 
susceptibility is very great, the exciting cause may be a trivial one. These 
causes may be grouped under three general heads: (1) direct irritation 
of the cortex of the brain; (2) reflex irritation; (3) toxic influences. 

Under the head of direct irritation may be included all convulsions 
occurring with the various forms of cerebral disease; the most frequent 
are meningitis, meningeal or cerebral haemorrhage, tumour, abscess, 
hydrocephalus, embolism, and thrombosis. As examples of reflex irri- 
tation may be classed the convulsions following severe injuries, renal or 
intestinal colic, retention of urine, phimosis, or a foreign body in the 
ear. A case has been reported to me in which the application of cold to 
the skin repeatedly induced convulsions. Other conditions classed under 
this head are dentition and worms, but both must be regarded as ex- 
ceedingly rare causes of convulsions. The exciting cause is very fre- 
quently the presence in the stomach or intestines of undigested food; 
such attacks are sometimes ascribed to reflex irritation, but the majority 
are better regarded as toxic. Acute and chronic indigestion are to be 
ranked among the most frequent causes of convulsions, both in infants 
and older children. In either there may be but one attack, or attacks 
may recur at intervals of a few months with a repetition of the cause. 
Of toxic origin may be considered not only the convulsions resulting 
from conditions like uraemia and asphyxia, but also those which occur 
at the onset or in the course of various infectious diseases, sometimes 
classed as febrile convulsions. They are very frequent at the onset of 
certain diseases, particularly pneumonia, scarlet fever, malaria, acute in- 
digestion, and gastro-enteric intoxication. In these cases the convulsions 
seem due partly to the intensity of the poison and partly to the sudden- 
ness with which it affects the nervous system. Convulsions occurring 
late in the course of many diseases may be due to toxic influences, espe- 
cially when associated with exhaustion of the nerve centres, from the 
prolonged disturbances of nutrition accompanying the febrile condition. 

In pertussis, which of all infectious diseases is the one in which con- 
vulsions are most frequent, several factors may be present: asphyxia 
due to a severe paroxysm, cerebral congestion or haemorrhage resulting 



CONVULSIONS. 651 

from such a paroxysm, or simply from the peculiar susceptibility of the 
patient brought about by the disease itself. 

Convulsions ending fatally are not infrequently associated with en- 
largement of the thymus gland. I have seen several such where there 
was found at autopsy great enlargement of the thymus, which weighed 
from one to one and a half ounces. Some of these infants were pre- 
viously healthy; some were rachitic. The similarity of all these cases 
indicated that the convulsions were in some way due to the enlarged 
thymus, but the exact explanation is not yet understood. 

Frequently recurring convulsions in infancy are very often associated 
with tetany. The symptoms of the latter condition may be so slight as 
to be readily overlooked ; or there may be no symptoms present except 
the characteristic electrical reactions. 

One attack of convulsions, whatever the cause, renders the patient 
more liable to a second, and where there have been several, they occur 
from causes which are less and less marked. 

An important element in the convulsions of infancy, according to 
Hughlings Jackson, is the lack of development of the higher cerebral 
functions, in consequence of which they do not exert the controlling in- 
fluence over the discharge of nerve force which they do in later life. 

The condition of the brain in the beginning of an attack of convul- 
sions is one of anaemia; this is shortly followed by venous hyperaemia 
which may be very intense. In infants who die during convulsions the 
brain and its meninges are usually found intensely congested. They 
may be the seat of punctate haemorrhages, and sometimes of more ex- 
tensive ones. The lungs are also deeply congested, and the right heart 
is generally distended with dark clots. The other lesions found are 
accidental. 

Symptoms. — In some cases prodromal symptoms are present, such as 
extreme restlessness, irritability, slight twitchings of the muscles of the 
face, hands, feet, or eyelids. More frequently, however, the attack comes 
quite suddenly with little warning. Usually the first thing noticed is 
that the face is pale, the eyes fixed, sometimes rolled up in their orbits ; 
in a moment or two convulsive twitchings begin in the muscles of the 
eye or face, or in one of the extremities, which usually rapidly extend 
until all parts of the body participate. In most cases the convul- 
sions become general, but they may remain unilateral even when not 
due to a local cause — a point which is often forgotten. The contraction 
of the facial muscles causes a succession of grimaces ; the neck is thrown 
back; the hands are clenched; the thumbs buried in the palms; and a 
quick spasmodic contraction of the extremities occurs. There may be 
some frothing at the mouth, and in all true convulsions there is loss of 
consciousness. Eespiration is feeble, shallow, and may be spasmodic. 
The pulse is weak; it may be slow or rapid; often it is irregular. The 



652 DISEASES OF THE NERVOUS SYSTEM. 

forehead is covered with cold perspiration. The face is first pale, then 
becomes slightly blue, especially aboirl the lips. Unnatural rattling 
sounds may be produced in the larynx. The bladder and rectum may be 
evacuated, The convulsive movements consist in an alternation of flexion 
and extension occurring rhythmically. All varieties of tonic and clonic 
spasm may be seen, and in all degrees of severity. The contractions of 
the two sides of the body are usually synchronous. After a variable time, 
from a few moments to half an hour, the convulsive movements are 
gradually less frequent, and finally cease altogether, usually leaving the 
patient in a condition of stupor. They may recur after a short time or 
there may be but one attack. A period of general relaxation usually fol- 
lows the convulsive seizures, frequently accompanied by marked evidences 
of prostration. Transient paralysis, apparently due to exhaustion of the 
nerve centres, is not an uncommon sequel. 

Death may take place from a single attack ; this, however, is rare ex- 
cept in very young infants, especially those who are rachitic or are suf- 
fering from status lymphaticus. There may be no sequel to the con- 
vulsions if the cause is a temporary one, or they may produce some serious 
brain lesion, particularly meningeal haemorrhage. Death from convul- 
sions is generally due to asphyxia, or to exhaustion from the rapidly 
recurring attacks. Many cases recover in which the children for several 
minutes had the appearance of being moribund. 

One attack of convulsions is very apt to be followed by others; for 
the occurrence of the first one usually reveals a peculiar susceptibility 
of the nervous system, and each succeeding attack comes from a less 
powerful exciting cause than the previous one. The longer the interval 
which has passed, the less likely is there to be a repetition, especially if 
the child has passed its third year. The number of attacks may be very 
great. In one case that I saw, an infant during the latter part of its 
second year had during six months over thirty-five hundred distinct 
attacks of convulsions. For a considerable period they reached the almost 
incredible number of eighty a day, and yet the mental condition of the 
child in the interval was apparently normal. 

Diagnosis. — There can rarely be any difficulty in recognising an at- 
tack of convulsions. The difficulty consists in determining with which 
of the many possible exciting causes we have to do in the case before us. 
If it comes with acute symptoms does it depend upon a cerebral lesion, 
or does it mark the onset of some other acute disease? Is it reflex, and 
if so to what is it due? If there are no acute symptoms, is it epilepsy? 
To answer these questions a careful history must be obtained, and all 
the circumstances surrounding the patient, the character of the con- 
vulsions, and all the other symptoms present must be taken into con- 
sideration. 

In infancy, epilepsy is the least probable diagnosis. In older chil- 



CONVULSIONS. 653 

dren the important points indicating that disease are: the presence of 
some of the stigmata of degeneration, a history of previous attacks, a 
distinct aura preceding the seizure, or a sudden onset with a cry or fall, 
biting of the tongue, a tonic spasm preceding the clonic, a deep sleep 
following the seizure, and, finally, perfect recovery in the course of a 
few hours. Convulsions which come on with high fever, even though 
a patient may have repeated attacks, are seldom epileptic. However, in 
some cases only prolonged observation can enable one to decide posi- 
tively whether or not epilepsy is present. 

Convulsions occurring in brain disease, except acute meningitis, are 
not as a rule accompanied by any marked rise in temperature. Focal 
symptoms are often present, such as localised paralysis or rigidity, 
changes in the pupils, and strabismus. The convulsive movements are 
frequently limited to one side of the body. It should, however, be borne 
in mind that unilateral convulsions, even when repeated, do not always 
mean a local lesion, as I have seen proved by autopsy more than once. 
In haemorrhage or meningitis, convulsions are likely soon to recur. In 
tumour they may recur after a longer interval. 

Convulsions may be thought to indicate the onset of some acute dis- 
ease when they occur in a child over two years old, and when they come 
on suddenly or with only slight premonition in a child previously well; 
but the most important point is that they are accompanied by a high 
temperature — 104° to 106° F. Acute meningitis is the only other con- 
dition likely to produce these symptoms. Whether the convulsions mark 
the onset of lobar pneumonia, scarlet fever, or some other disease, can 
,be determined only by carefully watching the patient's symptoms for 
twenty-four or thirty-six hours. 

In infants, derangements of the digestive tract should first be sus- 
pected; in very young infants relatively slight disorders may cause 
severe and repeated convulsions. In the first weeks of life one may 
often be in great doubt as to the cause of convulsions. Such attacks may 
be due to some disorder of the digestive tract, to a recent cerebral lesion 
like haemorrhage or to a defective brain development. Sometimes noth- 
ing but the progress of the case will definitely clear up the diagnosis. 

Examination of the urine should not be omitted in any case of con- 
vulsions of doubtful origin. Asphyxia may be suspected in the case of 
convulsions occurring in the newly born, late in pneumonia, in some 
cases of pertussis, in spasmodic or membranous laryngitis, or in laryn- 
gismus stridulus. Dentition and worms should be considered among 
the least probable, never as the most probable, causes of reflex irritation, 
and should not be so accepted without positive evidence. Worms are 
so rare in infancy that at this period they may be practically ignored. 
Dentition seldom causes convulsions except in patients who are markedly 
rachitic. In all cases of convulsions of doubtful or obscure origin oc- 



654 DISEASES OF THE NERVOUS SYSTEM. 

caning in infants, rickets should be suspected as the underlying cause, 
and the child carefully examined for other evidences of that disease. 
The close association of convulsions with tetany should not be for- 
gotten. 

Prognosis. — This depends upon the age of the patient and the cause 
of the convulsions. Idiopathic or reflex convulsions are rarely danger- 
ous to life except in very young or in rachitic infants. Convulsions as- 
sociated with enlarged thymus are often fatal. Convulsions occurring 
at the onset of acute febrile diseases are seldom fatal, and not often 
serious ; they may not even indicate an unusually severe type of the dis- 
ease. Especially fatal are the convulsions of pertussis and of asphyxia 
when they occur late in any form of laryngeal or pulmonary disease. In 
nephritis, while always serious, convulsions are by no means invariably 
fatal. The conditions during an attack which should lead one to make 
a bad prognosis are when the convulsions are prolonged or recur fre- 
quently; also the presence of very great prostration, a feeble pulse with 
cyanosis, or deep stupor. 

In the prognosis one must take into account not only the immediate 
result of the attack, but its possible outcome. In a highly nervous or 
susceptible child a convulsion often means very little. Permanent injury 
to the brain, simply as a result of an attack, I believe, to be very rare. 
The possibility of epilepsy is to be borne in mind in all cases where chil- 
dren over two years old have occasional attacks of convulsions, although 
it is unusual that this result is seen. The farther apart the attacks are 
and the more definite the exciting cause, the less likely is this to be 
the case. 

Treatment. — Summoned to a child in convulsions, a physician should 
go at once and remain until the attack has subsided. He. should take 
with him chloroform, a hypodermic syringe with morphine, a soft cath- 
eter or rectal tube, and a solution of chloral. In order to treat convul- 
sions intelligently one must have in mind the prominent pathological 
conditions. These are: acute cerebral hyperemia, a more or less severe 
asphyxia with pulmonary congestion, an overtaxed right heart, and 
a tendency to congestion of all the internal organs. The nervous 
centres are in a condition of such unnatural excitability that the slight- 
est irritation may bring on convulsive movements when they have tempo- 
rarily subsided. The patient should therefore be kept perfectly quiet, 
and every unnecessary disturbance avoided. Cold should be applied to 
the head — best by means of an ice cap or cold cloths — and dry heat and 
counter-irritation to the surface of the body and extremities. The time- 
honoured mustard bath causes so much disturbance of the patient that 
it can usually be dispensed with and the mustard pack substituted. The 
feet may be placed in mustard water while the child lies in its crib. The 
mustard pack and footbath should be continued until the skin is well 



CONVULSIONS. 655 

reddened. The degree to which counter-irritation of the skin should he 
carried will depend upon the condition of the pulse and the cyanosis. 

In controlling convulsions the three remedies which may be depended 
upon are the inhalation of chloroform, morphine hypodermically, and 
chloral. Chloroform is undoubtedly the most reliable remedy for an 
immediate effect, and should be used even in the youngest infant. At 
the same time that it is being administered, chloral should be given 
per rectum. The initial dose should be, at six months, four grains; at 
one year, six grains; at two years, eight grains, dissolved in one ounce 
of warm milk. It should be injected high into the bowel through a 
catheter, and prevented from escaping by pressing the buttocks together. 
It may be repeated in an hour if necessary. The effect of the drug is 
generally obtained in twenty minutes. If, in spite of the chloral, the 
convulsions show a marked tendency to continue as soon as the chloro- 
form is withdrawn, or if the enema of chloral has been expelled, morphine 
should be given hypodermically. When the heart's action is weak, this 
is probably the best of all remedies. Objections are urged against it 
only by those who have had no experience with its use. To a well- 
grown child two years old, T V grain may be given; one year old, tjV 
grain ; six months old, -^ grain. This dose may be repeated in half an 
hour if no effect is seen. The tolerance of opium in cases of convulsions 
is very marked, and sometimes double the doses mentioned may be re- 
quired. The only other agent of much value is oxygen. I have seen con- 
vulsions which continued in spite of all other means yield immediately 
to oxygen. This is most likely to be valuable in cases of convulsions due 
to asphyxia. 

When once under control, the recurrence of the convulsions may be 
prevented by keeping the patient for two or three days under the influ- 
ence of chloral with bromide of sodium, the amount of chloral being 
gradually reduced. If it is badly borne by the stomach and not easily 
retained by the rectum, either antipyrine or phenacetine may be used 
with the bromide. Where there is a strong tendency to recurrence of 
the convulsions, urethan is sometimes even more efficient than chloral. 
It may be given in the same or in slightly larger doses. 

As soon as the convulsions have ceased, the cause should be sought 
and treated. In infancy it is wise in every case to irrigate the colon 
thoroughly with warm water, to remove any possible source of irritation. 
If there is reason to suspect the presence of undigested food in the 
stomach, this may be washed out. Much more frequently it is in the 
intestines, and free purgation by calomel is advisable. If there is high 
temperature, this should be reduced by the cold bath or pack. Sec- 
ondary attacks are to be prevented by careful feeding, by improving the 
general nutrition by means of fresh air, iron, cod-liver oil, and phos- 
phorus. The last two are especially valuable in cases due to rickets. 



666 DISEASES OF THE NERVOUS SYSTEM. 



TETANY. 

Tetany is a condition characterised by extreme nervous and muscular 
irritability with tonic muscular spasm, which may be intermittent or 
continuous. It usually affects the muscles of the extremities, especially 
the hands and feet, more rarely the neck, face, and trunk. When limited 
to the hands and feet it is known as carpo-pedal spasm or arthrogryposis ; 
and although sometimes classed separately, this is really only one mani- 
festation of the same general condition. In infants, tetany is very fre- 
quently associated with laryngismus stridulus, this being present in fully 
two-thirds of the cases; but in older children this association is quite 
rare. General convulsions occur in from twenty to thirty per cent of 
the cases. Although tetany is not a very common disease in America, I 
believe that it is very often overlooked. In my hospital service I seldom 
see fewer than a dozen cases a year. 

Etiology. — While tetany may occur at any age, it is most frequent in 
infancy. Fully two-thirds of the cases are seen in the first two years of 
life. It is most common between the fourth and tenth month. Most of 
the attacks are seen in the winter months. In infancy, males are much 
more frequently affected. At this age it is rarely seen except when 
associated with rickets. It may follow broncho-pneumonia, pertussis, 
typhoid fever, rheumatism, or measles. There is usually present some 
derangement of the digestive tract. There may be acute diarrhoea or 
chronic gastric or intestinal indigestion. It is seen in rare cases with 
intestinal worms and with intussusception. The most common exciting 
cause appears to be an intoxication from the digestive tract or the irrita- 
tion of undigested food. Attacks in older children are very uncommon 
in this country. In girls, tetany may occur at the time of puberty, 
especially when menstruation is delayed. In animals and in man 
tetany regularly follows the complete removal of the parathyroid glands. 
Some pathologists consider the essential cause to be an absence of the 
secretion of the parathyroid or some disturbance of its function. While 
this may be accepted as one of the causes of tetany, it is by no means 
established that it is the only cause. Considerable evidence has ac- 
cumulated that tetany is in some way associated with disturbances of 
calcium metabolism; but in what way has not yet been proven. Much 
regarding the nature and cause of tetany remains to be solved by further 
investigation. 

Pathology. — Up to the present time the only constant anatomical 
lesions demonstrated in tetany are in the parathyroid glands. The most 
frequent one is haemorrhage which may be recent, or if old, other changes 
are present such as the formation of small cysts and pigmentation. 
While parathyroid changes have been found in many cases they are not 
uniformly present. 



TETANY. 



657 



Symptoms. — The spasm may develop abruptly, or it may be pre- 
ceded by sensory disturbances, such as pain, numbness, or tingling. The 
upper extremities are usually first affected, the spasm gradually becom- 
ing more severe and finally involving the lower extremities. Both sides 
of the body are equally affected. The position assumed by the hands 




Fig. 104. — Tetany, showing the Characteristic Position of the Hands and Feet. 

In a child two years old. 

is very characteristic: The fingers are flexed at the metacarpophalangeal 
joints and the phalanges extended; the thumbs are adducted almost to 
the little finger; the wrist is flexed at an acute angle, and the whole 
hand drawn somewhat to the ulnar side. If the spasm is very marked 
no motion is allowed at the wrist, but movements at the elbow and 
43 



658 DISEASES OF THE NERVOUS SYSTEM. 

shoulder are usually normal. The feet are Btrongly extended, Bometimes 
in the position of typical equino-varus. The lirst phalanges of the toes 
are flexed, ami the Becond and third rows extended; the plantar surface 
is strongly arched, and the dorsum oi' the foot is very prominent, stand- 
ing out like a cushion. The typical position of the hands and feet is 
well shown in Fig. 104. The tendo-Achillis stands out prominently. 
Motion at the hip and knee is generally free. The spasm in many cases 
is limited to the hands and feet ; more rarely the muscles of the thigh, 
usually the adductors, may be involved. In very rare cases the muscles 
oi' the trunk, the face, or the eye may he affected. 

The knee-jerk and the cutaneous reflexes are exaggerated, and there 
is abnormal response to mechanical irritation. Light percussion upon 
a nerve trunk often induces marked contraction of the muscles supplied 
by the nerve. This is particularly striking in the face. The contraction 
of the facial muscles following such irritation is known as " Chvostek's 
symptom " or the facial phenomenon. A spasm causing the characteristic- 
position of the hands or feet may be excited by pressure upon the nerve 
trunks, or by constricting the limb so as to cut off the circulation. This 
is known as " Trousseau's symptom.'' The most diagnostic feature of 
tetany is the electrical reaction. It is best obtained in the peroneal 
nerve. Under normal conditions there may be no contraction to the 
cathodal closure with a current of less than five milliamperes. In tetany 
such a contraction is regularly obtained with a current of this strength 
and often with a much weaker one. Also, a reaction highly suggestive 
of tetany is an anodal opening contraction with a current of less than 
five milliamperes, and less than one causing an anodal closure contrac- 
tion. The most diagnostic reaction, however, is a cathodal opening 
contraction with a current of less than five milliamperes or a tonic con- 
traction with cathodal closure with less than five milliamperes. 

Evidences of pain owing to the spasm are frequently present. It 
may be so severe as to cause children to cry out. Pain is induced by 
any attempt to overcome -the spasm, and sometimes it is constant. There 
is no loss of consciousness and no fever. The muscular contraction is 
generally continuous, although there may be periods of remission or 
even of intermission. When associated with laryngismus stridulus, the 
spasm is much increased during these attacks. 

The duration of tetany is from a few days to several weeks. The 
mild form, which is usually seen in infants, in many cases passes away 
spontaneously in one or two weeks, although there may be relapses and 
recurrences at variable intervals. The most important complication is 
general convulsions. These may come on at any time in the course of 
the attack. Spasm of the glottis may either precede or follow tetany, 
and by many is regarded as part of the disease. When associated they 
generally cease at the same time. 



LARYNGISMUS STRIDULUS. 659 

Diagnosis.— T he diagnostic features of tetany are bilateral spasm — 

in infants usually limited to the hands and feel -without loss of con- 
sciousness, the spasm being increased or excited by pressure upon the 
arteries or nerves, exaggerated reflexes, and the characteristic electrical 
reaction. Evidences of rickets are usually present. While the other 
Symptoms of tetany arc subject to considerable variation, the peculiar 
electrical reactions are always present and therefore diagnostic. Accept- 
ing this reaction as the pathognomonic sign of the disease, it will be 
found that tetany is often present when not suspected, and that many 
obscure nervous symptoms are due to this disease which otherwise might 
be misinterpreted. 

The severe form of tetany has been taken for tetanus; but that dis- 
ease is very rare except in the newly born, and trismus is generally the 
first symptom. Trismus is extremely rare in tetany. From meningitis 
and other forms of cerebral disease tetany is distinguished by the absence 
of cerebral symptoms. 

Prognosis. — Tetany per se is not fatal, but death may result from 
the development of general convulsions or in infants from the condition, 
usually some serious disturbance of digestion, which tetany complicates. 
If recovery occurs it is usually complete. 

Treatment. — The first indication is to discover and if possible re- 
move the cause, and this in most cases is found in the digestive tract. 
If rickets is present it should receive the usual treatment, both dietetic 
and medicinal. For the relief of- the spasm, the hot bath is a valuable 
remedy. This may be repeated two or three times a day. Drugs which 
have the power of allaying spasm should be given — bromides, chloral, or 
antipyrine. 

The specific treatment of tetany by parathyroid extract has not in 
my hands been followed by any appreciable benefit. I have seen it tried 
only in infants. Those who hold the cause to be a disturbance of calcium 
metabolism, would treat tetany by withholding calcium salts, or by 
administering them, according to their view of the part which calcium 
plays in etiology. "Whether calcium is given or withheld, seems to me 
to have no special influence upon the disease. I have seen no advantage 
in excluding milk and have seen the most satisfactory results when the 
feeding was carried on according to the indications afforded by the 
child's digestive symptoms, disregarding the tetany. In prolonged cases 
there is no doubt that the administration of cod-liver oil and phosphorus 
is beneficial. They are to be used as in rickets. 

LARYNGISMUS STRIDULUS— LARYNGO-SPASM . 

Laryngismus stridulus is a rather rare condition and belongs espe- 
cially to infancy. It is most frequently seen in children who are rachitic. 



660 DISEASES OF THE NERVOUS SYSTEM. 

and is associated with carpo-pedal spasm and with general convulsions. 
It is not to be confounded with ordinary spasmodic croup or catarrhal 
spasm o( the larynx. 

Spasm of the larynx may be seen in several conditions quite different 
from laryngismus stridulus, li terms one of the essential features of 
pertussis. It occurs both in infants and in older children from pressure 
upon, or irritation oi\ the pneumogastric or the recurrent laryngeal nerve 
by a tumour in the mediastinum, usually a tuherculous lymph node, or 
a retro-cesophageal abscess. There is a form of spasm which occurs in 
the newly horn accompanied by crowing inspiration; this is not frequent, 
and is rarely serious. 

Laryngismus stridulus is quite different from any of these conditions. 
It is peculiar to infancy, the great proportion of cases occurring be- 
tween the sixth and eighteenth months. Males appear to be more 
susceptible than females. The constitutional condition with which it is 
most often associated is rickets. In a large number of cases, but .not 
in all, there is cranio-tabes. Many writers believe that laryngismus is 
invariably of rachitic origin. Of fifty cases observed by Gee, there were 
found in all hut two unmistakable evidences of rickets. The disease 
occurs in delicate infants who have been closely confined in warm rooms, 
and it is probably on this account that it is more often seen in the 
winter and early spring than at other seasons. The exciting causes of 
this spasm may be a breath of cold air, or any form of nervous excite- 
ment, such as passion, fright, or crying. 

Symptoms. — The disease is often unnoticed by the parents until the 
attacks have become quite frequent, the first ones being mild, and the 
later ones more and more severe. Occasionally the very first paroxysms 
may be severe. Such an attack comes on suddenly. The child throws 
back his head, the face becomes pale, then livid, and for the time there 
is complete arrest of respiration. This continues for a few moments, 
during which the cyanosis deepens, and the child seems in great distress, 
making violent efforts to breathe. If the paroxysm is a very severe one, 
the asphyxia may be so great as to lead to loss of consciousness, and it 
may even be fatal, or the attack may terminate in general convulsions. 
In milder attacks, after fifteen or twenty seconds the muscular spasm 
relaxes, the glottis opens, and a long, deep inspiration occurs, with the 
production of a crowing sound. The " crowing attacks " of infants are 
usually of this nature but milder, and the arrest of respiration is only 
momentary. Such forms of spasm often come on without any evident 
cause, and may he repeated from two or three to twenty times a day. 
Between them the condition of the child may be normal or carpo- 
pedal spasm and other evidences of tetany may be present. Xot all the 
paroxysms in the same case are equally severe. A child may have in 
the course of a day a great many mild attacks, but only a few severe 



HOLDING-BREATH SPELLS. 661 

ones. General convulsions are seen in over one-third of the cases, and 
earpo-pedal spasm or tetany complicates a si ill larger proportion. II" 
tetany is present in the interval, it is always increased during the 

attacks. 

The duration of the disease varies from a few days to several weeks, 
or even months. In cases which terminate in recovery there is a gradual 
diminution in the frequency and severity of the paroxysms, until they 
finally cease altogether. The outlook is good, unless there are general 
convulsions. The cases in which fatal asphyxia occurs are very rare. 

Diagnosis. — This is to be made from catarrhal spasm of the larynx. 
The differential points have been mentioned under the latter disease. 
Owing to the occurrence of the paroxysms and the crowing sounds, the 
disease may be mistaken for whooping-cough, and in fact this diagnosis 
is not infrequently made. A careful examination of the patient during 
the attacks, the absence" of cough, and the frequent association of tetany, 
are sufficient to differentiate this from pertussis. 

Treatment. — During the attack the object is to break the spasm. In 
mild cases this may be done by sprinkling water in the face. In severe 
cases inhalations of chloroform may be required, and even intubation. 
Between the attacks the patient should be given either bromide and 
chloral, or antipyrine. Sodium bromide, gr. v, and chloral, gr. i, may 
be given every three or four hours to a child a year old until the fre- 
quency and severity of the attacks are controlled; afterward three times 
a day. My own experience with antipyrine in this disease leads me to 
the belief that it is more effective than bromide and chloral. When the 
symptoms are severe, two grains of antipyrine may be given every four 
hours to a child a year old, the dose being gradually diminished as the 
symptoms improve. 

Calcium chloride in some cases produces striking results. In others 
it is without apparent benefit. It should be given, in full doses, e. g., 
gr. vi, four or five times a day to a child of twelve months. 

The general treatment of the child is quite as important as drugs 
directed toward relieving the spasm. Gold sponging should be u^vd 
unless it occasions so much fright as to increase the number of paroxysms. 
Careful attention should be given to the diet. Children should be kept 
in the open air as much as possible. Cod-liver oil is needed in most 
cases, and rachitic cases are sometimes much benefited by phosphorus. 
In all cases the treatment should be continued for several weeks after 
the paroxysms have subsided. 

HOLDING-BREATH SPELLS. 

Attacks closely related to those which have just been described are 
met with which may perhaps be variations of the same disorder. To 



662 DISEASES OF THE NERVOUS SYSTEM. 

them the term " holding-breath spells " has been applied. They are seen 
most frequently in the latter pari of the first ami during the second 
year, and affect children oi' the extremely nervous type. Most of them 
are rachitic. The attacks may occur five or six times a day, of at in- 
tervals o\' several days. Beginning in infancy they may recur from time 
to time until the age of four or five years. In susceptible children almost 
any form of excitement may precipitate an attack. By far the most 
frequent are temper and fright. If anything is attempted to which the 
child strongly objects, e. g., a cold bath, inspection of the throat, or tak- 
ing away a toy, an attack may ensue. The child's face becomes flushed, 
then livid : there is general rigidity of the trunk and extremities, but 
rarely clonic spasm. This rigidity is followed by complete relaxation 
with loss of consciousness. The entire attack usually lasts about half 
a minute. There may be a crowing sound as the child catches his breath 
or there may be none. After a few minutes of quiet the child gets up 
and in a short time is apparently as well as ever. Most of those who 
are subject to attacks of this sort sooner or later have one or more gen- 
eral convulsions. Although in infancy these seizures may recur with 
alarming frequency, and extend over a period of several }^ears, in most 
cases with time and with improvement in general health they gradually 
become less and less frequent until finally they cease altogether. I 
have not seen these attacks accompanied by tetany, nor followed by 
epilepsy. 

In this condition there is apparently no effort on the part of the 
child to control his impulses, he simply "lets himself go." Parents, 
witnessing attacks coming on after correcting or disciplining a child, 
soon fall into the habit of indulging him in everything with the hope 
of avoiding them. Such advice, indeed, is often given by physicians. I 
believe it to be unwise. A much better plan seems to be to teach the 
child to control himself in everything no matter how small. While it is 
impossible to assert that the attacks can be brought on at will, such cer- 
tainly seems at times to be the case, and the development of the will 
power by every form of self-control seems to exert an influence in pre- 
venting these attacks, certainly in children who have reached the age 
of four or five years. 

The treatment of these children is first addressed to the general 
nutrition; many of them are anaemic and under weight. The feeding 
and general routine should therefore be the first concern. A life as 
much as possible in the open air and in the country is most desirable 
with freedom from every form of nervous excitement or undue nervous 
stimulation. They should be controlled, taught self-control, and treated 
tenderly, but with great tact and firmness. Drugs directed specifically 
to the control of the attacks have in my experience been of little 
value. 



EPILEPSY. 663 



EPILEPSY. 



Epilepsy may be defined as a disease in which there is an estab- 
lished disposition to convulsions of a certain type, with loss of con- 
sciousness, which have recurred until a habit of convulsions has become 
fixed. 

A distinction must be made between cases of so-called "idiopathic" 
epilepsy and those which are secondary to a definite lesion of the brain, 
such as tumour, sclerosis, or abscess. Convulsions of the latter char- 
acter are designated as "symptomatic" epilepsy, and are discussed in 
connection with the various diseases in which they occur. The nature 
of the attack may, however, be identical in both varieties, and may not 
differ from an ordinary attack of convulsions or eclampsia. 

The proportion of idiopathic cases in children is not so large as was 
formerly supposed; many of these have been shown to depend upon 
lesions once overlooked, particularly mild infantile cerebral paralyses. 

Etiology. — From a consideration of 1,450 cases of epilepsy, Gowers 
states that twelve per cent begin in the first three years of life, and 
forty-six per cent between ten and twenty years. The greatest tend- 
ency to the development of the disease is shown about the time of 
puberty. Females are rather more liable to be affected than males, 
although the difference in sex is slight. Heredity plays an impor- 
tant role in the production of the disease. In one-third of the cases, 
according to Gowers, there is a family history either of epilepsy or 
insanity. 

Not very infrequently epilepsy may be traced to convulsions occurring 
during infancy. Infantile convulsions are very common, and usually 
the cause which produces them is a transient one. The proportion of 
such cases which develop epilepsy later in life is certainly very small. 
One frequently meets with children from two to five years old who have 
occasional attacks of convulsions, often from apparently trivial causes. 
In my experience, the great majority of these also recover completely 
with proper treatment; a very few become epileptic. The first seizure 
is sometimes traceable to fright, great excitement, heat-stroke, or blows 
or falls upon the head even without any gross lesion. As reflex causes 
may be mentioned intestinal worms, phimosis, adenoid vegetations of 
the pharynx, delayed or difficult menstruation, and masturbation. Most 
of these are rare causes, but they may be sufficient to produce the dis- 
ease where a strong predisposition exists. 

Among the most important factors in producing a paroxysm, is in- 
testinal putrefaction associated with chronic constipation and chronic 
intestinal indigestion. I believe it to be one of the most important 
etiological factors in cases occurring in children, particularly as an ex- 
citing cause of the first attacks. 



664 DISEASES OF THE NERVOUS SYSTEM. 

Pathology. — It is not within the scope of this work to discuss the 
various theories which have been advanced. The following are the con- 
clusions reached by Growers: 

" The muscular spasm is to ho regarded as the result of the sudden 
overaction (discharge) i^i' nerve cells, the violent liberation of nerve 
force, ami the sensations which the patient experiences before losing con- 
sciousness must be due directly or indirectly to the same cause. The 
disease which excites convulsions is most frequently at the cortex, and 
when organic disease causes convulsions that begin locally, the disease 
is almost invariably at the cortex. In idiopathic epilepsy the convulsions 
sometimes begin in this way, and this suggests very strongly that in such 
the change occurs in the cortex. Epilepsy must then be regarded 
as a disease of the gray matter, most frequently of the gray matter of 
the cortex." 

While there is pretty general agreement that the seat of the morbid 
changes in true epilepsy is in the cortex, but little is yet definitely known 
as to the nature of these changes. It is probable that a great variety of 
lesions, many of which are apparently slight, may produce this disease. 

Symptoms. — Two distinct types of epileptic seizures are met with: 
the major attacks, or grand mal, in which there are severe convulsions 
lasting from two to ten minutes, with loss of consciousness, etc.; and 
minor attacks, or petit mat, in which the convulsive movements are 
slight and may be absent, and in which the loss of consciousness is often 
but momentary. Between these two extremes all gradations are seen. 

Grand Mal. — The onset may be sudden, without premonition, or it 
may be preceded by certain prodromal symptoms known as the aura. 
The aura may be motor, such as a local spasm of the hand, face, or leg; 
or sensory, such as numbness and tingling in any part of the body, or 
some abnormal sensation rising gradually to the head, at which time 
loss of consciousness occurs. The variety of sensations described by 
patients as indicating an attack is endless. There may be a sensation 
in one finger, in the face, tongue, eye, or in any part of the body; or the 
warning may be of a general character, like a tremor or a shivering 
sensation, or a feeling of faintness. There has also been described a 
visceral or pneumogastric aura, in which there is epigastric pain, some- 
times nausea, and a sensation of a ball in the throat; or there may be 
palpitation, or cardiac distress. There may be general giddiness or 
vertigo, or a sensation of fulness in the head; or feelings of strangeness, 
or a dreamy, dazed condition; and, finally, the aura may have reference 
to any of the special senses, most frequently to sight. Sparks may appear 
before the eyes, or flashes of light or colour, or strange objects may be 
seen; or there may he a momentary loss of hearing; or strange sounds 
may be heard. In most cases the aura is peculiar to the individual. 

At the beginning of the seizure the face becomes pale, the pupils 



EPILEPSY. 665 

widely dilated, the eyes rolled up in their orbits and fixed. Speedily 
there is loss of consciousness. Simultaneously with these symptoms, or 
immediately following them, there occurs a violent tonic muscular spasm 
to which are due the characteristic symptoms of the early part of the 
seizure, viz., the fall, cry, biting of the tongue, cyanosis, and evacuation 
of the bladder or rectum. The fall is forcible, violent; in fact, the 
patient is precipitated usually forward, and frequently Buffers injury, 
never sinking down as in a faint. The head is often strongly rotated to 
one side. The position of the hands is frequently that assumed in tetany. 
The cry is a hoarse, inarticulate sound, not very loud, and is due to 
forcible expiration, owing to spasm of the muscles of respiration with 
the glottis partially closed. The cyanosis is the result of tonic spasm 
of the muscles of respiration; it may be quite intense, so that the face 
is livid, bloated, and the features distorted. The spasm of the muscles 
of mastication causes the biting of the tongue. Evacuation of the bladder 
and rectum may result from contraction of their walls, or from spasm of 
the abdominal muscles. The violence of the muscular spasm in this 
stage may be very great; it has caused fracture of bones, rupture of 
muscles, and even dislocation of joints. 

The stage of tonic spasm may be only momentary, the patient passing 
almost at once into the stage of clonic convulsions. The usual duration 
is from ten seconds to half a minute. In the stage of clonic spasm 
which follows, the symptoms are those of an ordinary attack of con- 
vulsions. The muscular contractions are violent, and there is often 
frothing at the mouth. Gradually the muscles of respiration relax, air 
enters the lungs, and the cyanosis passes off. After the clonic spasm 
has continued for a variable time — from two or three minutes to half an 
hour — the muscular contractions become less and less frequent, and 
finally cease altogether. In a few minutes the patient may regain con- 
sciousness, look vacantly around, and in a dazed way perhaps ask what 
has happened, he being completely oblivious to all that has occurred. 
More frequently, however, he passes at once into a deep sleep, which 
continues for an hour or more, but from which he can be aroused. From 
this he usually wakens with a severe headache, which may continue for 
several hours. After this he often feels better than for several days 
preceding the attack. During the seizure the temperature may be 
elevated one or two degrees, but rarely more. The attack may be fol- 
lowed by a slight temporary paresis, or aphasia, hysterical phenomena, 
vomiting, and intense hunger. In very rare cases the urine may contain 
a trace of sugar. 

Petit Mai. — The minor attacks of epilepsy may present a very great 
variety of symptoms, and at times it is almost impossible to decide that 
these are epileptic, except from their periodical occurrence. They pass 
under the names of "spells," " attacks of dizziness," " fainting turns." 



666 DISEASES OF THE NERVOUS SYSTEM. 

etc. The most Btriking thing which stamps them as epileptic is the loss 
o\' consciousness, and this may be of short duration, sometimes only 
momentary, and so pass unnoticed. In some cases it is absent altogether. 
There is no fall, hut there may be a slight dropping of the head, a fixed 
8tare for a moment or two. and that is all. This may or may not be 
preceded by an aura. After such a mild attack the patient's mind may 
be somewhat confused, and he may do or say strange things. All sorts 
o\' curious acts have been performed in an automatic way by patients in 
the condition which follows an attack of epilepsy, which may perhaps 
he regarded as part of the attack. In rare instances even acts of violence 
may he done. 

The Mental Condition of Epileptics. — A careful distinction should 
be made between cases in which epilepsy is secondary to some organic 
brain disease, and the mental disturbances seen in cases of idiopathic 
epilepsy. The children who are the subjects of the latter disease, and 
who are perfectly normal mentally, are certainly few. All degrees of 
disturbance may be seen, from those who are simply dull, apathetic, back- 
ward in development, and uncontrollable in temper, to those who are 
melancholic, idiotic, and even maniacal. The earlier in childhood epi- 
lepsy develops, the greater is usually the mental disturbance seen, because 
of the effect of the seizures upon the brain during its period of active 
growth. 

Symptomatic Epilepsy. — This occurs most frequently in children as 
a sequel of cerebral palsy, usually with hemiplegia, and it may follow 
either the congenital or acquired form. Epilepsy may come on at any 
time after the onset of the paralysis — from a few months to five or six 
years. At first the attacks may be separated by long intervals, but they 
gradually become more frequent as time passes. The convulsions in 
post-hemiplegic epilepsy begin, as a rule, on the paratysed side, and for 
a long time they may be confined to that side ; but later they may become 
general, in which case they are indistinguishable from attacks of idio- 
pathic epilepsy. Severe seizures are more likely to be seen than are the 
mild ones. 

Course of the Disease. — In most cases seizures at first occur at long 
intervals, of perhaps a year, but later they become more and more fre- 
quent. Either the mild or the severe attacks may be first seen, and may 
remain throughout as the only type present, or they may be associated 
in the same case. There are most frequently seen occasional major 
attacks with a large number of minor ones. The interval between the 
epileptic seizures in most cases is from two to four weeks, although they 
may be of daily occurrence. Sometimes three or four seizures will follow 
one another closely, and then there will occur a long interval of im- 
munity. The seizures may come on either during sleep or in the waking 
hours, and in some cases for a long time they may occur only in sleep. 



EPILEPSY. 667 

Such cases present peculiar difficulties in diagnosis, and are often long 
unrecognised as epileptic. The general health of patients may be quite 

normal. 

Death rarely, if ever, results from epilepsy, except from some accident 
at the time of the seizures, or from the condition known as the status 
epilepticus; in this the attacks come on with great frequency and sever- 
ity, the patient at times passing rapidly from one convulsion into an- 
other, the temperature rising to 105° or 106° F., and death occurring 
either from exhaustion or in coma. 

Diagnosis. — In most cases there is little difficulty in recognising the 
major attacks when they occur by day. Nocturnal attacks may he diag- 
nosticated by the cry, the biting of the tongue, blood upon the pillow, 
sub-conjunctival extravasation, evacuation of the bladder or rectum, and 
the severe headache. Minor attacks present the greatest difficulties, and 
a positive diagnosis is often impossible until the patient has been 
watched for a long time. The most important points to be noted are 
sudden pallor, dilatation of the pupils, temporary loss of consciousness, 
or simply mental confusion, and sometimes the evacuation of the bladder. 

It is not always possible to distinguish between secondary or symp- 
tomatic epilepsy and the idiopathic or hereditary form, particularly if 
the case comes under observation late in the course of the disease. The 
points which go to establish the first form are: that the convulsive move- 
ments are partial, or limited to one side; that when they are general, 
they always begin in the same part of the body ; or that there is a history 
of partial or unilateral attacks for some time before the occurrence of 
any general convulsions. It is important in all cases to examine the 
patient carefully for signs of an old hemiplegia, the symptoms of which 
may be so slight as to be readily overlooked. A marked increase in the 
reflexes of one side is quite as conclusive evidence as is a distinct weakness 
of the arm or leg. In idiopathic epilepsy some of the stigmata of degen- 
eration are usually present. The sudden development of epileptiform 
seizures in a child previously healthy, and in whom there is no hereditary 
history of the disease, should always arouse the suspicion of organic 
brain diseases, especially tumour. 

Prognosis. — The danger to life in epilepsy is very slight. Death is 
generally due to some accident, particularly drowning, at the time of a 
seizure. The tendency to spontaneous cessation of the attacks is small, 
while the tendency to recurrence is very great. 

The prognosis in any given case depends upon the cause of the dis- 
ease and the duration of the symptoms. When the cause can be re- 
moved, and when the symptoms have lasted less than a year, the 
prospects of permanent cure are fairly good. This is particularly true 
of cases in which the epilepsy clearly depends upon gross errors in diet, 
with chronic intestinal indigestion. If an hereditary tendency to the 



668 DISEASES OF THE NERVOUS SYSTEM. 

disease is marked, if the epileptic seizures have developed apart from any 
adequate exciting cause, and if they have continued untreated or in 
spite of treatment for two or three years, the symptoms may perhaps 

be relieved, but there is little prospect of permanent cure. In the rases 
also which are due to Local irritation, like that resulting from an old 
meningeal haemorrhage, the prognosis is invariably bad, and only tem- 
porary relief is to be expected. A few cases of traumatic epilepsy have 
been cured and many have been greatly improved by a surgical operation. 

Treatment. — The first indication is to remove the exciting cause 
where one can be found. Particular attention should be given to the 
digestive organs. The most hopeful cases are those associated with dis- 
turbances of digestion, especially chronic intestinal indigestion with 
constipation. These cases are to be managed like others of the same sort 
in which epileptic attacks are not present. Meat should be allowed once 
a day and in moderate quantity. Milk should be given, diluted if neces- 
sary, also buttermilk and kumyss. Green vegetables, peas and beans, 
may be given freely; also all fresh fruits. Tea, coffee, and alcohol in 
every form must be absolutely prohibited. The most careful attention 
should be given to the bowels. Under no circumstances should a condi- 
tion of chronic constipation be neglected. A dose of calomel once a week 
and intestinal irrigation two or three times a week are of great value 
in many cases. When the symptoms of intestinal putrefaction are 
marked, borax is at times of value — two grains three times a day to 
a child of five years — or salicylate of sodium, salol, or the benzoate of 
sodium may be given; the dose of each being from two to ten grains, 
according to the age of the child, after each meal. The general hygiene 
of the patient must receive careful attention. He should lead a simple, 
regular life, as much as possible out of doors, away from all sources 
of excitement. 

All the foregoing means of treatment are of equal importance with 
the use of special drugs. The most common mistake is to rely only upon 
drugs, ignoring the other measures mentioned. It not infrequently 
happens that drugs are without any effect when they are the only means 
of treatment employed, whereas in conjunction with other measures 
marked improvement is seen. 

The bromides are unquestionably the best means of combating the 
epileptic habit. Either the sodium salt alone or a combination of the 
sodium and ammonium or strontium bromide is to be preferred. The 
purpose should be to give the smallest doses which will control the 
seizures. Children require proportionately larger doses than adults, and 
in most cases a child of five years will need from twenty-five to fifty 
grains a day. The method of administering the bromides is of some 
importance. The larger part of the quantity for twenty-four hours 
should be given shortly before the time when the seizures have usually 



CHOREA. 669 

occurred; in the interval much smaller doses. In most cases it is desir- 
able to give a full dose at bedtime. Bromides should always he given 
largely diluted — in from six to eight ounces of water. 

Cases of petit mal are especially difficult to control. For such there 
is often an advantage in combining belladonna with the bromides. In 
all cases the treatment must be continued for a long time if anything 
is accomplished. The bromides sbould be gradually reduced after the 
attacks are controlled, but must be given in moderately large doses for 
at least two years after the seizures have ceased. Sometimes the combina- 
tion of chloral or antipyrine with bromides is advantageous, particularly 
if the latter are badly borne or cause an annoying amount of acne. 
Seguin states that be lias been able to control tbe acne in many cases by 
giving at the same time moderate doses of arsenic. 

Cases have been reported of very striking benefit following the use 
-of calcium lactate. It should be given in full doses, at least thirty grains 
a day for a considerable period. 

The surgical treatment of epilepsy has of late attracted much atten- 
tion. An operation is to be considered in cases in which the paroxysms 
are very frequent and severe, and when there is present a definite local 
cause, such as an old fracture of the skull, or when epilepsy has followed 
an injury to the head even without fracture. 

Tbe education of epileptic children is a subject of great difficulty and 
is often neglected. There are many reasons why it is impracticable to 
send them to ordinary schools, and it is therefore very desirable that 
special schools and colonies for them should be established. 

The Management of the Attack. — Abortive measures are sometimes 
successful in cases with a distinct aura, the most reliable being the inha- 
lation of nitrite of amyl. While the seizure lasts, the patient should be 
prevented from injuring himself. The clothing should be loosened, a 
spool or cork should be placed between his teeth to protect tbe tongue, 
but no effort made to restrain his movements unless he is likely to do 
violence to himself. An epileptic child should never be without some 
companion. 

CHOREA. 

(Saint Vitus' s Dance.) 

Chorea is a functional nervous disease characterised by aimless, irreg- 
ular movements of any or all the voluntary muscles. Choreic movements 
are of a somewhat spasmodic cbaracter, often accompanied by an ap- 
parent or real loss of power in the groups of muscles affected, and by 
a mental condition of extreme .irritability. 

Etiology. — Chorea is most frequently seen between the ages of seven 
and fourteen years. Of 1-16 cases, 6 were under five years, 72 between 
five and nine years, and 68 between ten and fourteen years. The 



070 DISEASES OF THE NERVOUS SYSTEM. 

youngest case of which I have record was thai of a child four years old. 
It is extremely rare before the third year, although it may occur even 
in infancy. My own observations coincide with those of nearly all writ- 
ers, that the disease is more than twice as frequent in females as in males. 
While chorea may be seen at all seasons, it is much more frequent in the 
spring months. Of 717 attacks studied by Lewis (Philadelphia), the 
largest number began in March, and the next largest number in May; 
in my own cases May stood first. 

The relation of chorea to rheumatism is of much importance. The 
investigations of different writers have given results which are somewhat 
contradictory. Some have found evidences of rheumatism in but a small 
proportion of the cases — in not more than five or ten per cent — while 
the statistics of others have placed the percentage with rheumatism as 
high as fifty or even sixty per cent. The question hinges largely upon 
what is to be admitted as evidence of rheumatism in a child; if cases of 
acute articular inflammation onty, then the number will be very small ; if 
subacute cases with joint swellings are included, the proportion will be 
considerably larger ; while if we admit cases of acute endocarditis without 
articular symptoms, and those of articular pains and joint stiffness but 
without swelling, the proportion will be very much increased. My own 
belief is that there is a very close connection between chorea and the 
rheumatic diathesis as manifested by all the symptoms above noted, and 
accompanied by a family history of rheumatism. There seems to be a large 
group of cases, therefore, which may be classed distinctly as rheumatic. 
There are, however, a few others in which no such element can be found. 

My former associate, Dr. F. M. Crandall, has analysed 146 cases of 
chorea treated by us in an out-patient clinic and in private practice, with 
the following results: Of 111 cases in which the question of rheumatism 
was investigated there was a definite history of it in 63. In 41, rheu- 
matism occurred before the chorea; in 13, the first evidence of rheu- 
matism was coincident with the chorea; and in 9 it first occurred subse- 
quently to the chorea, usually within three months. In about one-third 
of the cases, attacks of rheumatism occurred during or subsequent to the 
chorea as well as before it. It may then be stated that previous rheu- 
matism was evident in 37 per cent, concurrent rheumatism in 24 per 
cent, and subsequent rheumatism in 15 per cent of the cases. Excluding 
cases mentioned twice, and also all those in which there was a history 
only of " growing pains," there was evidence of articular rheumatism in 
56.7 per cent of the cases. Many of these patients have now been under 
observation for several years, and it has been interesting to see, as time 
has passed, how the evidences of rheumatism have multiplied the longer 
the cases have been followed. 

In the above statistics only articular symptoms have been accepted 
as evidence of rheumatism. If the cases of endocarditis without articular 



CHOREA. 67] 

symptoms were included, as T think they might fairly be, it would raise 
the proportion of rheumatic eases still higher. The great proportion 
of cardiac murmurs persisting after chorea, if not all of them, should, 
I believe, he classed as rheumatic, even if no articular symptoms have 
been present. 

Overpressure in school is often an important element in the produc- 
tion of chorea. Ansemia, if not an essential factor, is certainly a very 
important one, and the great proportion of eases present very distinct 
evidences of it. Chorea may develop as a sequel of any of the infectious 
diseases, more particularly scarlet and typhoid fevers. Among the reflex 
causes ma} r be mentioned phimosis, either luinbricoids or pinworms, 
delayed menstruation, and ocular defects, although the latter more fre- 
quently cause a local spasm of the muscles of the eyes, which can hardly 
be considered choreic. Hereditary influence is of considerable importance 
in the production of chorea. It is much more frequent in children of 
neurotic families, and ver} r often several successive generations, or sev- 
eral children in the same family, may sutfer from the disease. 

The exciting cause of chorea in a certain proportion of cases is fright ; 
occasionally it arises from imitation, and the disease has been known to 
occur epidemically in institutions. 

The role of bacteria in the production of rheumatic chorea is still 
undecided. The organism which Poynton and Paine have described 
as the cause of acute articular rheumatism has been found in the 
meninges of the brain in a few fatal cases of chorea. 

Pathology. — The exact pathology of chorea is at the present time not 
settled. The seat of the morbid process is undoubtedly the central 
nervous system, probably the motor areas of the cortex. The cases asso- 
ciated with rheumatism are now generally regarded as of infectious 
origin. In some severe cases which were fatal, owing to association with 
acute endocarditis, capillary emboli have been found in the brain. How- 
ever, it is by no means established that this is the condition present in 
most of the rheumatic cases. The fact that in the great majority of such 
cases complete recovery occurs in the course of a few weeks or months, 
speaks strongly against any important structural change in the nervous 
centres. In cases not rheumatic, the most probable explanation of the 
symptoms is to be found in vascular changes, having their origin in 
disturbances of nutrition. 

Symptoms. — An attack of chorea generally comes on gradually. At 
first the child may be considered simply as unusually nervous; if at 
school, there may be noticed a difficulty in writing, drawing, or in using 
the hands for other delicate operations. At home, tin 1 child is con- 
tinually dropping things, has difficulty in feeding himself, sometimes in 
buttoning his clothes, and very frequently he is not brought to the 
physician until the symptoms have lasted a week or two. Sometimes 



672 DISEASES OF THE NERVOUS SYSTEM. 

the legs are first affected, and a history is given of frequent falls, a 
Btumbling gait, difficulty in going upstairs, etc. At other times the 
spasm is first soon in the facial muscles, with disturbance of articulation, 
twitchings of the eye muscles, and the child may ho punished for making 
grimaces. In most cases the spasmodic movements soon extend to all 
parts o( the body. They remain limited to one side of the body (hemi- 
chorea) in about one-third of the eases. When fully developed, the move- 
ments of chorea are quite unmistakable. They are irregular, jerking, 
spasmodic, never rhythmical, rarely symmetrical, and vary in intensity 
from an occasional muscular contraction to almost constant motion. The 
movements are not under the control of the patient's will, and are usu- 
ally intensified by efforts to repress them. They are increased by excite- 
ment, embarrassment, or fatigue, but do not continue during sleep. 

Very often there is weakness of the affected muscles, which may be 
so great as to lead to the suspicion that actual paralysis exists. Xot 
infrequently I have had patients brought to the clinic for supposed 
paralysis, either of one extremity or of one side of the body, where the 
choreic movements have not been severe enough to attract the attention 
of the mother. This paralysis usually disappears in the course of a 
few weeks. 

In severe forms of chorea the patient may be unable to walk, to speak 
intelligibly or even to sit up in bed. Control of the bladder or rectum 
may also be lost. The symptoms may be so intense as even to endanger 
life. Such cases, however, are dangerous, not from the choreic move- 
ments, but from the acute endocarditis with which they are frequently 
associated. 

The mental condition of choreic patients is one of marked irritability. 
They are fretful, emotional, easily provoked to tears or laughter, and 
difficult to control. In extreme cases a mental disturbance bordering 
upon acute mania has been observed. In other cases the facial expression 
and manner of speech strongly suggest beginning imbecility. All degrees 
of speech disturbances are seen from the slight difficulty in articulation 
due to inability properly to control the movements of the tongue and lips, 
to a condition in which speech is almost impossible. In severe eases 
speech may be temporarily lost. 

Cardiac murmurs are frequent in chorea. Some of these are of 
anaemic origin, some possibly are due to chorea of the cardiac muscle it- 
self — although this is a matter of some uncertainty — but a large number, 
probably the majority, are due to concurrent endocarditis, as is shown 
by the fact that they are permanent, and are followed by all the signs 
of organic heart disease. During every attack the heart should be 
closely watched, especially in children in whom there is a strong pre- 
disposition to rheumatism. 

The general condition of choreic patients is usually much below 



CHOREA. 673 

normal. They arc anaemic] the appetite is poor, often capricious; they 
Bleep very badly; they Buffer frequently from headaches; they arc easily 
fatigued by Blight muscular exertion; and in short they have all the 
symptoms of a greatly disturbed nutrition. 

Course and Duration. — The ordinary form of chorea tends to spon- 
taneous recovery in from six to ten weeks. Exceptionally it may Last for 

three or four months. In a small number of casts the disease may be- 
come chronic and continue indefinitely. Certain forms of local spasm, 
particularly choreiform movements of the muscles of the faa 
neck, may be permanent. In any case of chorea which lasts longer than 
the usual time, the patient should be carefully examined for some cause 
of peripheral irritation. The tendency to relapses and second attacks is 
very marked. Later attacks are likely to occur in the spring succeed- 
ing the first illness, and in a small number of patients attacks may come 
every year for four or five years. 

Diagnosis. — There is little difficulty in recognising chorea from the 
sudden, irregular, spasmodic contraction of the muscles coming on under 
the circumstances indicated. Xo other movements of childhood are 
likely to be confounded with it. The form of chorea following hemi- 
plegia is usually more athetoid than choreic, yet at times it closely simu- 
lates ordinary chorea. The difficulty in distinguishing between the two 
is often increased by the fact that the weakness of simple chorea may, if 
unilateral, closely simulate hemiplegia. The existence of rigidity, con- 
tractions, and increased reflexes belongs exclusively to hemiplegic cases, 
and these will usually suffice to clear up all doubt with reference to the 
diagnosis. 

Prognosis. — As a rule, this is favourable, and complete recovery can 
usually be predicted, the exceptions being few in number. Parents should 
always be warned of the tendency of the disease to return in succeeding 
years, and the fact should be stated that in a certain proportion of cases 
the disease may be permanent. The prognosis of the cardiac murmurs 
occurring in chorea should always be guarded, although some of these 
are functional and disappear with recovery from the chorea; but the 
number of those which do not disappear is sufficiently large to make one 
always apprehensive as to the ultimate result. Acute chorea accompanied 
with endocarditis may be fatal ; a number of such cases are on record 
in which there was no other evidence of rheumatism. 

Treatment. — The general management of the case is equally im- 
portant with the administration of drugs. A child with chorea should at 
once he taken from school, and should never be subjected to punishment 
or to ridicule on account of the movements. Special attention should 
be given to the patient's diet and general nutrition. Tonics, especially 
iron, are indicated in most cases. The food should be simple and nutri- 
tion-, and all stimulants, particularly tea and coffee, should he absolutely 
44 



674 DISEASES OF THE NERVOUS SYSTEM. 

prohibited. While fresh air is desirable, exercise should be prescribed 
with great caution and its effed should be carefully watched. A cer- 
tain amount of moral restraint is indispensable; thus it often happens 
that choreic patients do very badly at home where they are indulged 

and receive sympathy, while in a hospital, where they are under 
restraint and made to control themselves, they begin to improve im- 
mediately. In all severe eases the " rest treatment" should be employed. 
It is equally benefieial in the milder ones; the patient is put to bed, 
and complete mental and physical rest secured. This may be combined 
with gentle massage for fifteen or twenty minutes a day. The daily 
use of warm baths, either alone or in conjunction with massage, is de- 
cidedly benefieial. In other cases the regular use of cold douches is 
of value. 

With reference to the use of drugs, it is advisable to separate from 
other cases those in which the connection with rheumatism is very close. 
In the rheumatic eases, salicylate of soda is often efficient, while the 
drugs usually employed may be absolutely without effect. In the non- 
rheumatic cases, arsenic is undoubtedly a valuable remedy. Beginning 
with four drops of Fowler's solution three times a day for a child of 
eight years, the daily quantity may be increased by one drop every two 
or three days until eight drops are given at each dose. One should stop 
short of this if digestion is disturbed, or tbere is pufhness of the face 
or albumin in the urine. Arsenic should always be given after meals, 
and largel} r diluted. The possibility of arsenical poisoning should be 
remembered, although it is rare. Semple has reported a case in which 
multiple neuritis and general pigmentation of the skin occurred after 
four weeks' administration of the drug. 

Antipyrine and strychnine sometimes succeed where arsenic fails. 
From fifteen to twenty grains of antipyrine should be given daily in 
divided doses to a child of eight years. To a child of eight years strych- 
nine should be given in doses of -gV of a grain three times a day, the 
dose being gradually increased until double this quantity is given. 
Acute chorea of great severity may require opium, or bromides and 
chloral. 

In estimating the value of drugs in the treatment of chorea, the natu- 
ral course of the disease should be kept in mind, since those drugs which 
are taken after the third or fourth week are much more likely to be 
thought beneficial than those used in the early period of the attack. 

Chorea has a strong tendency to recur, especially in the spring 
months. Children who have had one attack should he closely watched, 
particularly with reference to their work in school. They should not be 
crowded in their studies, they should have long vacations, and the nerv- 
ous system should not be put upon any severe tension for a long time. 



OTHER SPASMODIC AFFECTIONS. 675 

OTHER SPASMODIC AFFECTIONS. 

Habit Spasm. — This term is used to describe certain spasmodic mus- 
cular movements which at first arc only occasionally noticed, hut which 
may persist until they become habitual and almost entirely involuntary. 
The movements usually affect the muscles of the face, hut they may he 
seen in almost any part of the body. The most Erequenl varieties consist 
of blinking or sudden frowning, raising the eyebrows, or some peculiar 
grimace. At other limes there is sudden twisting of the head, Bhrugging 
of the shoulders, or jerking of the hands. It is not often seen in the 
lower extremities, but the muscles of respiration are quite frequently 
affected. There may be a half-sigh, a sort of sob, or a peculiar dry, 
laryngeal cough. 

These movements are at first infrequent; but as the habit becomes 
more firmly fixed the spasm recurs every few minutes, and in severe 
cases it may be almost continuous. The form of spasm is not always 
the same; one may disappear and another take its place. The condition 
may last for months or years, and it may even be permanent. 

Habit spasm is really little more than exaggerated nervousness con- 
tinuing in some definite form until by repetition a fixed habit is estab- 
lished. It is different in cause, course, prognosis, and treatment from 
chorea, with which, however, it is often confounded. 

The causes are those of neuroses in general. In the beginning, at 
least, the general health is usually below the normal. The patients 
are nervous children of neurotic antecedents. There may be a history 
of some definite exciting cause, such as illness or overwork in school. 
There may be some local cause of which the spasm is merely a reflex. 
Common ones affecting the facial muscles are visual defects, adenoids, 
and carious teeth. 

Habit spasm is to be differentiated from chorea ; this is usually easy, 
from the limitation of the movements to one part or group of muscles 
and from the duration of the disease. 

Treatment is quite unsatisfactory after the habit has become fixed, 
hence it is of very great importance that it should be arrested at the 
earliest possible age. Punishments are of no avail, and usually aggravate 
the condition. Rewards are much more effectual. The general health 
should receive attention and nerve tonics should be given, especially 
strychnine. 

Athetosis and Athetoid Movements. — These terms, introduced by Ham- 
mond, are used to describe a chronic form of spasm usually seen in the 
hand, hut sometimes also in the toot, and even the face. It may affect 
both sides, but in most cases it is unilateral. The movement is slow, 
irregular, and incoordinate — a sort of " mobile spasm," it has been 
called — and there may be associated a certain amount of muscular rigid- 



676 DISEASES OV THE NERVOUS SYSTEM. 

ity. Such movements rarely occur in persons apparently healthy, but 
are usually soon as a sequel of cerebral palsies, generally hemiplegia. 
Recovery from the paralysis may be so Dearly complete that the athetoid 
movements are looked upon as primary. In some cases the movements 
are more rapid and somewhat resemble those of chorea, the condition 
being sometimes classed as posthemiplegic chorea. Athetosis is not in- 
fluenced by treatment. 

Rotary and Nodding Spasm of the Head. — These are rare forms of 
irregular movements usually observed in infancy. The condition was 
described long ago by Henoch. The most frequent is the rotary spasm, 
which consists in a side-to-side oscillation of the head, which may be 
slow or rapid, and in some cases is almost continuous. Some children 
have at times the nodding spasm also, and in others this is the only 
movement seen. Nystagmus is frequently associated, and may affect one 
or both eyes. In a few of the reported cases convergent strabismus was 
present. 

The causes of the condition are extremely obscure. It is usually seen 
in infancy between the third and eighteenth months, and, like most nerv- 
ous symptoms of this period, has been ascribed to dentition, but without 
any special reason. In three of the cases reported by Hadden, it followed 
an injury to the head, and might perhaps be regarded as a result of cere- 
bral concussion. 

As a rule, the condition lasts for several months and improves, recov- 
ery generally taking place. The prognosis is therefore usually favour- 
able. 

Nystagmus. — This term is applied to rhythmical, involuntary, oscil- 
latory movements usually of both eyes. They are caused by the alter- 
nate contraction of opposing muscles. Nystagmus may be either vertical 
or horizontal. It is most often seen in infants a few months old, and is 
a symptom of irritation which may be general or local. In some cases 
the movement is almost continuous, occurring even in sleep; in others, 
it is only noticed at times of special excitement. 

The etiology of nystagmus is obscure, and it may occur in quite a 
variety of conditions — sometimes referable to the eye, at other times to 
the central nervous system. On the part of the eye, nystagmus may be 
due to blindness from any cause, to congenital cataract, corneal opacity, 
disease of the choroid or retina, or to errors of refraction. It may be 
seen in almost any organic disease of the nervous system, both with focal 
and diffuse lesions, especially in chronic hydrocephalus, insular sclerosis, 
tul>ereulous meningitis, and in diseases in which sight is impaired. 
Nystagmus may be of reflex origin, as in a case recently occurring in the 
Babies' Hospital, where an infant with a severe diarrhoea had repeated at- 
tacks, which disappeared each time after intestinal irrigation. While it is 
of no importance as a localising symptom, nystagmus usually indicates 



OTHER SPASMODIC AFFECTIONS. 677 

something more than functional disturbance. An exception to this may 
perhaps be made when it follows cerebral concussion. In such cases h is 
usually temporary, disappearing in a few days or weeks. Under most 
other conditions it may continue indefinitely. 

The condition of the eyes should be investigated in every case of 
nystagmus; it is only when the cause is here, and can be removed, that 
habitual nystagmus is amenable to treatment. 

Hiccough (Singultus). — This is a spasm of the diaphragm which is 
usually seen in young infants. In them it is in most cases due to some 
irritation in the stomach. It is seen after eating, and may depend upon 
overfilling of the stomach with food, swallowing of air, etc. In other 
cases it has no relation to the taking of food, and is to be regarded as 
a form of reflex spasm, which may occur from a variety of causes, such as 
cold feet, chilling of the surface during the bath, or suddenly taking an 
infant from a warm bed into a cold room. In cases like the above, 
hiccough, though sometimes annoying, is of little importance. It may 
be associated with gastric indigestion, with intestinal flatulence or inflam- 
mation, with peritonitis or intestinal obstruction. With the last two 
conditions it is always an unfavourable symptom. In older children 
hiccough sometimes occurs as a pure neurosis. 

The object of treatment is to remove the cause. In infants this is 
to aid in the expulsion of the gas from the stomach by manipulation, Im- 
position, or the other means useful in gastric colic. When it is a nervous 
symptom only, it may be arrested by holding the breath, by prolonged 
forced expiration, as in blowing a trumpet, and sometimes it may he re- 
lieved by drugs which control muscular spasm, e. g., antipyrine or chloral. 

Thomsen's Disease (Congenital Myotonia). — This rare disease is usu- 
ally congenital. It may occur in several members of the same family, 
and is often hereditary. The characteristic symptoms are a peculiar 
rigidity of the muscles which is observed when they are first brought 
into action after repose. This rigidity is spasmodic, and usually con- 
tinues but a few moments. It may recur when voluntary movements 
are again attempted. If, however, muscular effort is persisted in, it 
soon passes off. It is increased by apprehension, excitement, or cold, and 
by observation. The legs are most frequently affected, the condition 
being often noticed when the patient starts to walk ; any of the voluntary 
muscles, however, may be involved. It may be greater upon one side of 
the body than upon the other. The muscles are abnormally sensitive 
to mechanical stimulation, and often to galvanism. They are above 
normal size, and the fibres themselves are enlarged. 

The pathology of this disease is, according to Gowers, an altered 
functional condition of the muscle fibres, and an abnormal functional 
state of the nerve cells of the cord and the cortex. It is incurable, 
although the symptoms may be improved by active muscular exercise. 



678 



DISEASES OF THE NERVOUS SYSTEM. 



Cervical Opisthotonus. — This is usually a symptom of disease at the 
base o( the brain, occurring with cerebro-spinal, tuberculous, and chronic 
basilar meningitis, sometimes with tumours of the posterior fossa of the 

skull. However, in certain cases it occurs as a form of reflex spasm, 
particularly in young infants who are suffering from diarrheal diseases 
or marasmus. In these cases it may last for days or weeks. The de- 
formity is produced by a contraction of the superior fibres of the trapezius 
and by the posterior group of cervical muscles. 

Torticollis — Wry-neck. — Torticollis is usually produced by a tonic 
spasm of one sterno-mastoid muscle, with which may he associated spasm 
of the posterior cervical muscles, including the trapezius. In recent 
cases there is simply a condition of muscular spasm; in those of long 
standing there may be permanent shortening of the affected muscle, 
atrophy, and partial paralysis. A somewhat similar deformity may be 
caused by cicatricial contraction of the tissues of the neck following 
burns. 

The deformity varies somewhat according as the sterno-mastoid 
muscle is alone affected, or the posterior muscles also, and as to which 

predominates. In simple ster- 
no-mastoid spasm the head is 
inclined to the affected side and 
rotated toward the opposite 
side; the chin is raised, and 
the ear approaches the clavicle. 
"When other muscles are in- 
volved the deformity is modi- 
fied. If the trapezius is af- 
fected (Fig. 105) there is less 
rotation of the head, but it is 
drawn to the affected side and 
somewhat backward, while the 
shoulder is raised and the spine 
curved. Both of these symp- 
toms may be seen to a slight 
degree in almost any marked 
case of sterno-mastoid spasm. 
Sometimes the spasm of the 
posterior muscles affects both 
sides ; the head is then drawn 
backward and held rigidly but without rotation. In most of the recent 
cases the deformity can he partially or entirely overcome by passive force: 
but after a time this is impossible, owing to muscular shortening. In 
recent cases localised pain and tenderness are also frequently present, 
and sometimes thev are Bevere. 




/ 



Fig. 105. — Spasmodic Torticollis. Trape- 
zius and sterno-mastoid of the left side are 
affected. 



OTHER SPASMODIC AFFECTIONS. 679 

Etiology. — Spasmodic torticollis may be produced by anything caus- 
ing irritation oi' the trunk or the branches of the spinal accessory nerve; 
the source may he in the spinal canal, in the cranium, along the course 
of the nerve trunk, or oi' any of its peripheral fibres. 

Torticollis may he congenital or acquired. Regarding the cause of 
congenital torticollis there is some dispute. Such cases have often been 
attributed to the contraction resulting from haematoma of the sterno- 
mastoid. It is my belief that this is rarely if ever the ease. While it 
is possible that the deformity is sometimes the consequence of injury 
received during delivery, the cause of most of the congenital cases goes 
back to conditions existing before birth. It may be compared to club- 
foot, and may be due to a faulty position of the child in utero, or it may 
come from more serious conditions, such as malformations, or unequal 
development of the two sides of the body. 

A frequent cause in the acquired cases is irritation of the spinal ac- 
cessory nerve by an enlarged cervical lymph gland; such is the usual 
etiology of torticollis following scarlet fever, measles, or diphtheria. I 
have seen it in the early stage of quinsy, and it may occur in cellulitis 
of the neck. A cause which the physician should always have in mind is 
cervical Pott's disease; torticollis may be the earliest, and for several 
weeks sometimes almost the only, objective symptom of this disease. 
Torticollis coming on acutely is most frequently due to cold (rheu- 
matism?), occasionally to malaria. I have notes of eight cases clearly 
traceable to malaria, and have seen at least a dozen others. In the so- 
called rheumatic torticollis, muscular pain and soreness are rather more 
prominent than in the other forms. 

Prognosis.— The result in a case of torticollis depends upon the 
cause, the severity, and the duration of the deformity. Most of the 
acute cases recover, under appropriate treatment, in the course of a 
few weeks, sometimes in a few days. The congenital cases with slight 
deformity are usually amenable to mechanical or postural treatment if 
begun early. There is, however, in most of the other varieties a dis- 
position of the deformity, if untreated, to persist, and even to increase. 
If it has lasted several months the probabilities of spontaneous recovery 
or even of improvement are small. 

Treatment. — The first indication is to remove or treat the cause 
when one can he found. Malarial cases require quinine; rheumatic 
cases are benefited by rest in bed, hot applications, counter-irritation, 
friction, and sometimes by anti-rheumatic remedies. (Vases which have 
lasted a month usually require some orthopaedic head-support, and those 
which have lasted six months or more are rarely cured without a surgi- 
cal operation. This may be either a subcutaneous tenotomy or myotomy 
of the sterno-mastoid, or an open incision. Whitman gives the result 
of thirty-two hospital cases, as follows: In seventeen in which the de- 



680 DISEASES OF THE NERVOUS SYSTEM. 

formity had Lasted less than six months, ten were cured, the average 
duration of treatment being three months; four were improved, and 
throe not improved, the average duration of treatment in these cases 
being eleven months. Of fifteen rases in which the deformity had 

lasted over six months, none were cured and only six improved, after an 
average o[' about eight months' treatment. In the foregoing series of 
eases the treatment consisted mainly in the use of orthopaedic apparatus; 
later results from incision have been considerably more favourable. But 
these figures show how serious a matter is an old case of torticollis, and 
emphasise the importance of resorting to radical measures early in the 
disease. 

HYSTERIA. 

This is not a disease of childhood, but one which is occasionally 
seen in early life. All that will be attempted in this chapter is to point 
out the most common manifestations of hysteria when it occurs in chil- 
dren. After puberty it is essentially the same as in adults. 

Etiology.— Hysteria is very rare before the seventh or eighth year, 
and most of the cases seen in children occur after the tenth year. As to 
sex, there is no such predominance of females as in later life, although 
even in childhood they are more frequently affected than males. Hered- 
itary influences play an important part in the production of this disease. 
It is seen in children who inherit a nervous constitution, or in whose 
parents nervous diseases, such as insanity, or hysteria, or alcoholism have 
been present. Of the other etiological factors the most important are a 
disordered nutrition, frequently with anaemia or chlorosis, and over- 
pressure in schools. Masturbation or phimosis may act as an exciting 
cause, or, indeed, anything which leads to an exalted nervous irritability 
and depreciation of the general health. It may follow any of the acute 
infectious diseases; or it may be excited by injury, fright, or imitation. 

Symptoms. — There is scarcely any disease in which the clinical pic- 
ture presented is so varied as in hysteria. It may simulate almost any 
form of organic disease of the brain, lungs, digestive organs, bones, or 
joints. The most common symptoms may be grouped under four general 
heads. These are, however, seen in almost every conceivable combi- 
nation. 

1. Psychical Symptoms. — When these predominate there may he seen 
periods of mental depression of longer or shorter duration, a change 
in disposition, an indifference to surroundings, a capricious humour, or a 
nervous condition of extreme irritability with irregular paroxysms of 
laughter or weeping without cause. There may be great excitability of 
temper, and fits of passion almost maniacal in their severity. There 
may be various hallucinations. Sleep is frequently disturbed, some- 
times by attacks resembling ordinary night-terrors; sometimes somnam- 



HYSTERIA. 

bulism is present. There is often a disposition to deception about the 

most trivial matters, which may last for weeks. There is a tendency to 
imitate the symptoms of various diseases, which the patients may have 
witnessed in others or about which they have read. 

2. Sensory Symptoms. — These are the most frequent manifestations 
of hysteria in early life. There is often general or local hyperaesthesia, 
which may be so great as to simulate inflammation of the various 
internal organs. Anaesthesia is much less common, although it may 
be seen in children as young as eight or nine. Headache is an occasional 
symptom, and is sometimes associated with great tenderness of the scalp. 
There may be neuralgias in the different parts of the body, or sharp 
epigastric pain, sometimes accompanied by vomiting. Sometimes the 
special senses are affected, giving rise to hysterical blindness or deafness, 
usually of short duration. 

3. Joint Symptoms. — These are really a variety of sensory dis- 
turbances. They are not uncommon, and are often most puzzling. The 
symptoms may be referable to the spine, or to any of the large joints, 
particularly those of the lower extremity. All forms of organic disease 
of these joints may be simulated. They are usually seen between the 
ages of ten and fourteen years, and occur in both sexes. There may be 
lameness referred to one of the large joints, curvature of the spine, or 
torticollis. The symptoms are most frequently referred to the hip, and 
next to the knee, the ankle, or the spine. The pain is often acute. It 
is increased by motion, and by attempts at overcoming the deformity, 
if any is present. There is a marked hyperesthesia of the whole Limb, 
and sometimes of the body. In nearly every case there is marked tender- 
ness of the spine upon pressure, especially in the dorsal region. The 
deformity may be very slight from spasm of the flexors only, or it may 
be severe, and followed by contracture, so that the thighs may be flexed 
tightly against the abdomen with the heels against the buttocks. Such 
deformities may last for months. There may be considerable muscular 
atrophy, but only that which comes from disuse. A special difficulty in 
diagnosis arises from the circumstance that these symptoms occasionally 
follow an injury. 

Organic disease of bones and joints may usually be excluded by 
attention to the following points: The mode of onset is more abrupt 
than is seen in bone disease, and the course of the disease is quite ir- 
regular. The degree of deformity is greater than is seen in hone dis- 
ease of the same duration. There is general hyperesthesia of the limb, 
acute tenderness of the spine upon pressure, and undue sensitiveness to 
heat or cold. The deformity varies from time to time, being always more 
marked when examination is attempted. If the patients are closely 
watched, other evidences of hysteria may be seen. Under complete anaes- 
thesia the contractures may disappear entirely. There is no enlargement 



682 DISEASES OF THE NERVOUS SYSTEM. 

of the articular ends of the bones, do swelling of the soft parts, and no 
evidence of active inflammation or of suppuration. All the symptoms 
except the deformity are subjective. Under proper treatment there is 
in most rases perfect recovery, often in a surprisingly short time. 

I. Motor ami Convulsive Symptoms. — In the milder forms there are 
seen many varieties o\' tonic or clonic spasm. There may be local 
spasm of the eyes, face, or mouth, spasm of the museles of the neck 
producing torticollis, of the muscles of respiration causing dyspnoea, 
which may be constant or paroxysmal. There may he hiccough, or spasm 
of the larynx causing hysterical aphonia. A very common symptom is 
hysterical cough, which may be so frequent and so severe — even accom- 
panied by haemoptysis — that grave disease of the lungs is suspected : the 
chest, however, is free from the physical signs of disease. There may he 
frequent attacks of vomiting with eructations; these may be continued 
sometimes even for months, and in rare instances blood has been vom- 
ited. There may be dysphagia from spasm of the oesophagus, or regur- 
gitation of food on attempts at swallowing. In more severe cases we may 
have the symptoms of chorea major and attacks of hystero-epilepsy. The 
latter are rare in children and do not differ essentially from such attacks 
in older patients. There are usually prodromal symptoms. The con- 
vulsive movements are exceedingly varied in type. There are painful 
sensations and sensitive areas, by pressure upon which hysterical symp- 
toms may be increased or even convulsions excited. The respiration 
may be rapid or irregular. All variations in tonic and clonic spasm may 
be seen. Opisthotonus is frequent. Consciousness is not fully lost, but is 
disturbed, and hallucinations are present. The temperature is normal. 

Hysterical paralysis is not common in children, but it may be seen 
even in the very young. Other symptoms occasionally seen in hysteria 
are persistent anorexia, polyuria, sometimes incontinence of urine, dis- 
turbance of the secretion of saliva or perspiration. 

The general condition of hysterical patients is usually below the nor- 
mal. They are poorly nourished and anaemic; they sleep badly; they 
have capricious appetites and feeble digestion. 

Diagnosis. — Hysteria is apt to be overlooked because its occurrence in 
children is not considered as often as it should be. In most cases the 
diagnosis is easy if hysteria is suspected. A combination of vague dis- 
connected symptoms is usually present which admits of no other ex- 
planation. Organic disease can be excluded only by careful and repeated 
examinations. It is to be borne in mind, however, that hysteria not 
infrequently complicates organic or constitutional disease. Much im- 
portance is to be attached to a family history of rrysteria or of other 
neur< - 

Prognosis. — Tins is better than in adults, especially if the cases are 
taken in hand early, before the disease has become deeply seated. Very 



HEADACHES. 683 

much depends upon how well the directions for treatment can be carried 
oui. The prognosis is less favourable when the hereditary tendency is 
strongly marked. In many cases there arc relapses later in life. 

Treatment. — Prophylaxis is of much importance. When a hered- 
itary tendency to oervous diseases exists in a family, or whenever very 
nervous children are placed under the physician's care, every means 
should be taken toward muscular development, keeping the oervous sys- 
tem in the background. Such children should lead an out-of-door life 
as much as possible, preferably in the country. They should keep early 
hours, have regular exercise, and their education should be directed with 
moderation and judgment, special attention being paid to regularity of 
work and the prevention of overpressure in schools. Theatres and ex- 
citing hooks should he avoided. All stimulants, including tea and 
coffee, should he absolutely forbidden. The diet should be plain and 
nutritious. It is highly important that such children should he re- 
moved from association with an hysterical mother, when this is possible. 
The best results are usually obtained when the child is taken from his 
home surroundings and placed in some quiet retreat in charge of an 
intelligent nurse. 

In the general management of a case of hysteria, it is of the first 
importance that the child should be cared for by a person of firmness, 
who can exercise proper control. Hysterical children are always man- 
aged more easily when they are removed from their homes and placed 
under the charge of a good nurse. Sometimes they can be managed in 
no other way. Isolation is absolutely essential in many cases. The 
general health should be carefully looked after, and arsenic, iron, cod- 
liver oil, and other tonics given according to indications. Horseback 
exercise and other out-of-door sports should he encouraged, and every 
means taken to interest the child in something which requires physical 
exercise. In eases of simulated disease, the child should be put to bed, 
no books or toys allowed, and no effort made toward his amusement. 
Xo sympathy should be exhibited, but the child should be treated with 
kindness and firmness. This moral treatment is quite as important as 
any other part of the therapeutics. In cases with hysterical joint symp- 
toms the most valuable thing is counter-irritation to the spine, prefer- 
ably by the Paquelin cautery. Under no circumstances should mechan- 
ical force he used to overcome deformity. .Many cases of hysteria 
improve under hydrotherapy; the cold douche, the cold pack, or the 
shower hath may he used. This is valuable in conjunction with massage 
and the u rest treatment." 

HEADACHES. 

Headaches are not common in little children except in conned ion 
with disease of the 1 brain or meninges: in older children they occur from 



()S4 DISEASES OF THE NERVOUS SYSTEM. 

causes similar to those seen in adult life. The most frequent headaches 
may be grouped in the following classes: 

1. Toxic II ('(((laches. — Such are the headaches resulting from uraemia, 
from malaria, and those Been in many acute in feet ions diseases. But 
the largest uumher are associated with chronic indigestion and con- 
stipation. 

2. Headaches from Anosmia, Malnutrition, and Nerve Exhaustion. — 
These are most frequently seen in girls from ten to fourteen years old. 
Some are intellectually bright, and have been crowded in their school 
work; others are dull and learn only with difficulty, and in consequence 
worry over their work until their health becomes undermined. They 
sleep badly, lose appetite, and often become choreic. The anaemia may 
be either the cause or the result of these symptoms. 

:\. Headaches of Nervous Origin. — These may occur in children who 
are highly neurotic, either from their inheritance or surroundings, and 
in those who are the subjects of epilepsy or hysteria, and they may be 
symptomatic of organic disease of the brain, such as tumour or tuber- 
culous or syphilitic meningitis. True facial neuralgia is rare in child- 
hood except from carious teeth; from this cause, however, it is not in- 
frequent. 

4. Headaches due to Disease of some of the Organs of Special Sense. 
— In connection with the eyes there may be conjunctivitis, keratitis, 
iritis, errors of refraction, or strabismus; connected with the nose there 
may be polypi, hypertrophic rhinitis, or adenoid vegetations of the 
pharynx; connected with the ears there may be otitis or foreign bodies 
in the canal. Each one of these conditions requires special treatment. 

5. Headaches due to Inherited Gout or Rheumatism. — These are not 
very frequent, but they may be severe, and may at times simulate the 
onset of meningitis. They are often accompanied by pains in the joints, 
muscles, or nerve trunks. 

6. Disturbances of the genital tract are rarely a cause of headaches in 
children, although this may be the case in girls about the time of pu- 
berty, especially where menstruation is delayed or difficult. 

Diagnosis. — The diagnosis of headaches includes the discovery of the 
cause, and this is often difficult. In an infant or a young child, organic 
disease of the nervous system should always be suspected as a cause of 
severe headaches. In older children the important things to be con- 
sidered, because the most frequent, are digestive disturbances, nervous 
exhaustion, malnutrition, and visual disorders. An absolute diagnosis 
in a case of j persistent headache can be made only by a careful physical 
examination, not omitting a study of the urine; often there must be a 
close observation of the patient for some time. 

Treatment. — The only successful treatment is that which is directed 
toward a removal of the cause. Each one of the different groups above 



DISORDERS OF SPEECH. 685 

mentioned is to be managed differently, according to the principles eke 
where laid down regarding the treatment of these conditions. For the 
relief of the Bymptom, cold to the head, a hoi foot-bath, and phenacetine 
in moderate doses are perhaps the most certain of all remedies. 



DISORDERS OF SPEECH. 

In this chapter will he discussed only functional speech defects, those 
depending upon organic conditions being considered in connection with 
diseases of the brain. The most common varieties arc stuttering, stam- 
mering, lisping, alalia, backwardness, and functional aphasia. All forms 
are much more frequent in boys than in girls, the proportion being more 
than four to one. 

Stuttering. — This is the most common form of speech disturbance. 
Articulation is distinct and the separate sounds are properly produced, 
but there is a difficulty in connecting the consonant with the succeeding 
vowel; this seems like an obstacle to be overcome. Occasional stuttering 
is seen in very many children. It is more frequent in the third and 
fourth years, before speech is thoroughly mastered. At this age it is 
aggravated or produced by disturbances of nutrition, but is usually 
of temporary duration, lasting for a few weeks or months. Only recently 
a little boy of four was under my care, who became very anaemic, slept 
poorly, and suffered from malnutrition as a result of the confinement 
incident to a home in the city. He soon began to stutter, and in a short 
time it became painfully marked. After a few weeks in the country he 
improved very much in his general condition, gained four or five pounds 
in weight, and his stuttering completely, and I think permanently, dis- 
appeared. Such disturbances as this are analogous to chorea. In other 
cases stuttering follows some acute illness, and under such conditions 
also it is usually of short duration. 

Most children who become habitual stutterers do not begin until they 
are six or seven years old, and sometimes even later. Stuttering may 
arise from imitation, and inheritance is an important etiological factor. 
It is frequently a mark of degeneration. 

It is important that all such cases receive early treatment before 
i he habit becomes firmly fixed. The prognosis is good for spontaneous 
recovery in nearly all the cases seen in very young children, and also in 
those coming on after acute illness. Other cases in which the condition 
has become habitual should have the benefit of systematic training under 
a competent teacher in breathing and vocal gymnastics. 

Stammering. — This term is sometimes used synonymously with stut- 
tering. Kussmaul makes the distinction between them that, in stam- 
mering, individual sounds are difficult of production, while in stuttering 
it is syllabic combinations. Stammering is often accompanied by some 



686 DISEASES OF THE NERVOUS SYSTEM. 

defect in the organs oi' articulation the teeth, lips, tongue, or palate— 
which is not present in Btuttering. 

The treatment consists in careful training and in the correction of 
whatever abnormal local conditions may exist. 

Lisping. — In this there is an imperfect production of certain sounds, 
owing usually to a faulty position of the organs of articulation. The 
sounds may he so indistinct that they can not be understood. In this 
condition also there may be defective formation of some of the organs 
of articulation, although in the milder forms this is not the case. The 
treatment is similar to that of stammering. 

Alalia. — This consists in a total inability to articulate. It is seen in 
all young infants during their earliest attempts at talking. In older 
children it is usually associated with some mental defect. 

Backwardness. — Backwardness is carefully to be distinguished from 
a late development of speech due to mental defects. At two years old 
children not deaf are almost invariably able to speak. Speech may be 
late in consequence of prolonged or very severe illness, and when it has 
once been acquired it may be lost from similar causes. 

Functional Aphasia. — The term has been applied to a temporary loss 
of speech -which sometimes occurs in chorea, and sometimes from severe 
fright or anything else which has produced a marked nervous impression. 
West records an instance in a girl of eight years, who was suffering from 
an attack of chorea induced by fright. Speech first became difficult and 
then was lost altogether. For a month the child could say only " Yes " 
and " No." The case improved very slowly, but at the end of nine weeks 
had recovered completely. Loss of speech sometimes follows the acute 
infectious diseases, especially typhoid fever. 

In all disorders of speech, the functional cases are to be distinguished 
from those which depend upon deafness and mental deficiency. The 
frequency with which these disorders are due to disturbances of general 
nutrition, and to local causes in the mouth and throat, should be borne 
in mind, and these conditions should receive their appropriate treatment 
early, before the habit of defective speech becomes firmly established. 
For the latter class of unfortunates, special training at the hands of a 
competent teacher should be advised, preferably in an institution. 

DISORDERS OF SLEEP. 

Disturbed Sleep, Sleeplessness. — Disturbed or restless sleep is much 
more common in infancy and childhood than is true insomnia, although 
the causes of the two conditions may be the same. 

Etiology. — In infancy these symptoms are most frequently due to 
hunger or to indigestion resulting from overfeeding or improper feeding. 
Very often disturbed sleep is the result of bad habits, such as rocking 



DISORDERS OF SLEEP. 687 

during sleep or night-feeding. Sometimes it arises from dentition, <>r 

the pain of colic or otitis; at other times it may be simply the expression 
of a condition of extreme aervous irritability, the result of inheritance 
or of the child's surroundings. It is often caused by the persistent activ- 
ities of a fussy nurse or mother. 

In later childhood the first thing to he suspected when sleep is much 
disturbed is some derangement of the digestive organs; in this will he 
found the explanation of fully half the cases. The most frequent type, 
when the symptom is of long duration, is chronic intestinal indigestion, 
often associated with indicanuria, a condition in which formerly the 
usual diagnosis was intestinal w T orms. Other cases are due to obstructed 
respiration from adenoid growths of the pharynx or enlarged tonsils, 
sometimes to nocturnal attacks of asthma. A lack of fresh air in the 
sleeping room, excessive or insufficient bedclothing, and cold feet, are 
other frequent causes. Disturbed sleep with "starting pains" is one of 
the earliest symptoms of hip-joint disease. In the nervous exhaustion 
resulting from overpressure in schools, and in malnutrition and anaemia, 
disturbances of sleep are well-nigh constant. They are also seen in 
organic cardiac disease and in all pulmonary conditions accompanied by 
dyspnoea or cough. Sleep may he disturbed in consequence of bad dreams 
which have their origin in exciting stories heard or read just before 
bedtime, or in too violent or exciting play. To discover the cause in 
almost any case it is necessary to investigate carefully the w-hole routine 
of the child's life. 

Symptoms. — The condition may be one of real insomnia which may 
last for w T eeks or months; or the sleep may be simply disturbed and rest- 
less, the child waking many times during the night, and when asleep 
will not lie quietly, but constantly changes his position. Sometimes 
children wake suddenly with a scream, but immediately drop off to sleep 
again. 

Treatment. — The essential treatment consists in the discovery and 
removal of the cause of the disturbance. This will often involve a radical 
change in the manner of feeding, in the hygiene of the nursery, and in 
all the surroundings of the child. A change of nurses sometimes results 
in a speedy cure. Under no circumstances should the physician coun- 
tenance the use of drugs to promote sleep in children, except in the rase 
of severe acute disease. Soothing syrups and all nostrums for "teeth- 
ing"* should be absolutely forbidden; also the sucking of a "pacifier." 
Many mothers and nurses fall into the habit of using them, because the 
injurious effects are not appreciated. When the cause of sleeplessness is 
found and removed the child will sleep, hut compulsory Bleep obtained 
under other conditions is usually productive of more harm than good. 
If food, diet, and all bad habits have been corrected, nervous causes 
should be investigated. When no cause can he discovered the treatment 



888 DISEASES OF THE NERVOUS SYSTEM. 

should consist in putting- the child upon the simplest possible diet, and 
in attention to such general conditions as anaemia, malnutrition, and 
neurasthenia, some of which are almost certain to be present. In many 
rases a warm hath at bedtime will be found beneficial. A quiet, darkened 
room, plenty of fresh air, and the stopping of both eating and drinking 
during the night, are essential to a cure in most cases. When the con- 
dition accompanies some acute disease, the drugs which are most useful 
are codeine and tnonal. A child of two years may take gr. -£$ of codeine 
or two grains of trional as an initial dose, to be increased ii' necessary. 

Night Terrors — Pavor Nocturnus. — Two classes of cases have been 
grouped under this head, both having this in common, that sleep is dis- 
turbed by fright. 

The condition in the first group partakes of the nature of nightmare. 
It may he due to partial asphyxia from adenoid growths of the pharynx, 
or to other causes mentioned under disturbed sleep, or it may be gastric 
or intestinal in its origin. These cases are quite frequent. Sleep may 
be disturbed from the outset, and the attack may be merely the culmina- 
tion of such disturbance. The child w r akes in a state of fright and ex- 
citement, and often says he has had a bad dream. His mind is clear, he 
recognises those about him, but it may be a long time before he is suffi- 
ciently calm to sleep again. The attack may be remembered perfectly 
the next day. Cases like this are to be managed in the same general way 
as those of disturbed sleep above mentioned. 

In the second group are the only cases to which the term " night ter- 
rors " should really be applied. These are relatively rare, but the condi- 
tion is a much more serious one. The symptom is generally due to some 
disturbance of the central nervous system. It occurs especially in those 
of neurotic antecedents, or those who have previously suffered from 
infantile convulsions, and it is often the precursor of other nervous at- 
tacks — migraine, hysteria, epilepsy, and even insanity. The attack usu- 
ally comes suddenly where a child has previously been sleeping quietly, 
and more frequently in the early part of the night than later. He is 
generally found sitting upright in his bed in a bewilderment of terror, 
being " afraid of the dog," or " the bear," or there is some other vision 
or hallucination which has produced the fright. Often this is associated 
with something of a red colour. The child does not recognise those 
about him, does not know where he is, and may go to sleep again with- 
out coming to full consciousness. The next day there is no recollection 
of what has happened. Usually no after-effects are seen, but sometimes 
a Large amount of pale urine is passed. The attacks may be repeated 
at intervals of a few months, or they may occur every few nights; but 
whatever the peculiar nature of the vision, it is likely to be repeated in 
nearly the same form. Such attacks have something in common with 
epileptic seizures, and the diagnosis between them may at times be dif- 



INJURIOUS HABITS OF INFANCY AND CHILDHOOD. 089 

ficult. They arc to be regarded seriously, qoI only on accounl of -what 
they are in themselves, bul on accounl of what may follow. 

Treatment. — Al] mental and nervous strain should be mosl carefully 
avoided, and when the attacks arc frequenl the bromides should be given 

at bedtime. Sonic person should sleep in the same room with the child, 
or in an adjoining one with the door open. 

Excessive Sleep. — It is rare that cither infants or children Bleep an 
unnatural amount of the time unless one of two causes is present — or- 
ganic brain disease, most frequentl) r tuberculous meningitis, or the use 
of drugs. The latter is always to be suspected if with the sleep there is 
associated obstinate constipation. Opium in the form of " soothing 
syrup " or paregoric is the drug which has usually been given. 



INJURIOUS HABITS OF INFANCY AND CHILDHOOD. 

On account of the close connection of such habits with disturbances 
of the nervous system, they may be properly considered with the func- 
tional nervous diseases. Although some of these habits may not be of 
serious importance, yet as a group they usually receive too little atten- 
tion at the hands of the physician. The list is very long, and only the 
most important ones will be discussed. 

Sucking. — This is a very common habit in infants, and during the 
first few months it is seen to some degree in most of them. If they are 
carefully watched the habit is easily stopped; otherwise it may continue 
indefinitely. Young infants usually suck the fingers when hungry, and 
this can scarcely be considered abnormal, but an effort should always be 
made to stop it, lest the habit become fixed. Lindner distinguishes be- 
tween simple sucking and sucking with combinations. In the former, 
the child sucks some part of the body, such as the thumb, fingers, toes, 
tongue, lips, back of the hand or arm, or it may be some foreign sub- 
stance, such as part of the clothing, the blanket, a rubber nipple, or the 
" pacifier." This is the most common form that is seen. In the second 
variety the sucking is accompanied by the rubbing of some other parts, 
which seems to afford a pleasurable excitement; this may be the ear, the 
genitals, or any other portion of the body. Sometimes sucking is accom- 
panied by some practice which produces actual pain, such as pulling of 
the hair or scratching the body. Habits of sucking often persist through- 
out infancy, and not infrequently throughout childhood ; they have often 
been known to continue up to puberty. The longer the habit lias lasted 
the more difficult is it to break. 

The results of sucking may be serious. Deformities of the thumb or 
finger, of the lips and teeth, and even of the jaws, art 1 sometimes pro- 
duced. I knew a woman whose thumbs to advanced age showed a de- 
formity resulting from the habit of thumb-sucking while a child. In 
45 



690 DISEASES OF THE NERVOUS SYSTEM. 

her case the habit was not broken until Bhe was eight or nine years old. 
Probably the most pernicious result of sucking is its tendency to develop 
the habit of masturbation. Habitual sucking of one hand or finger may 
lead to spinal curvature. 

Treatment.— In the management of these eases the most important 
thing is to arrest the habit early, before it becomes fixed. Too often the 
habit of thumb-sucking, or of sucking a rubber nipple, is encouraged by 
mothers, nurses, and sometimes even by physicians because of the tem- 
porary quiet which is thereby produced. Under no circumstance should 
it be resorted to as a means of putting children to sleep or otherwise 
quieting the nervous system. With infants, the only treatment which 
is at all successful is mechanical restraint. It is of no use to cover the 
part which is sucked with bitter solutions. The hands of young infants 
may be covered with mittens, or with the long sleeves of a night-gown 
which is pinned to the bed, so that it is impossible for the child to get 
the part to the mouth ; or, still better, cuffs or splints of pasteboard may 
be applied at the elbow, so as to prevent flexion of the arms. In the 
milder eases the habit is often discontinued spontaneously; but when 
it lias been indulged in until a child is four or five } r ears old, it is broken 
only with the greatest difficulty. Punishments are of little avail, but 
rewards are often successful. 

Masturbation. — This is not uncommon even in infancy. Many cases 
have been observed during the first year, and some as early as the sev- 
enth or eighth month. It is seen in children of all ages and in both 
sexes; but in infants and very young children it is, in my experience, 
very much more common in girls than in boys. 

Etiology. — Local causes are present in a large number of the cases, 
and they are usually something which produces undue irritation. The 
most frequent are, long or adherent prepuce, phimosis, balanitis, vulvo- 
vaginitis, eczema of the labia, threadworms, and tight clothing. A urine 
which is irritating because of excessive acidity or the presence of crystals 
of uric acid may be a cause. Any irritation may lead the child to rub 
the parts in some way, and a pleasurable sensation being excited, this 
action is repeated until a habit is formed. Other causes are exercises 
in which the legs are rubbed together, or the body against a pole, as in 
climbing. To these causes must be added, in infants at least, the habit 
of sucking. After infancy the habit of masturbation is usually acquired 
from other children, but sometimes taught by vicious nurses. 

General causes are also important as predisposing factors. These 
are the same as underlie most of the neuroses of childhood — viz., marked 
anaemia, general malnutrition, and a highly neurotic constitution, which 
is often an inheritance, and is always aggravated by surroundings which 
tend to unnatural stimulation of the nervous system. When masturba- 
tion develops in a young child without any local cause, it may be an 



INJURIOUS HABITS OF 1MANCY AM) CHILDHOOD. 691 

early sign of cither mental deficiency or moral delinquency ; if looked 
for, other stigmata of degeneration will usually be found, and In most 
cases other vicious trails will soon appear. 

Symptoms. — In infants and very young children masturbation is 
usually accomplished by thigh friction or by rubbing the body against a 
pillow, a chair, or some other object. The variety of wavs is almost end- 
less. Frequently the child will simply lie upon the floor with the thighs 
crossed and rigidly held, and sway the body backward and forward. This 
lasts for a few moments, is accompanied by flushing of the face and 
some appearance of excitement, followed by relaxation, and often by 
perspiration. It frequently happens with little children that these 
"queer tricks," as they are often regarded, have been continued for 
months hefore their true nature is suspected. 

A consciousness that they are doing something wrong early leads 
even young children to seek seclusion when they repeal the habit. It 
is especially likely to he practised when children lie long awake alone 
after they go to hed, or if they wake early. The habit is a! wavs 
made worse by any deterioration of the general health. 1 have known 
children, who were thought to be cured, to relapse under such con- 
ditions. 

It is somewhat difficult to separate the general symptoms with which 
masturbation is associated, and upon which it largely depends, from 
those which are the direct result of the habit. There are some children 
in whom the condition is chiefly or entirely dependent upon a local cause, 
or when it is only occasionally practised, in whom no general symptoms 
are seen, or at most only an unnatural shyness and a disposition \< 
seclusion. Others are precocious and excitable, with an excessive amount 
of nervous sensibility. There are others in whom more marked nervous 
symptoms are present; the most striking are absent-mindedness, loss of 
poweT of concentration, loss of interest in all amusements, and mental 
depression. Some girls of only seven or eight years may have fairly 
regular periods in which masturbation is practised. In one of my pa- 
tients such periods for a considerable time occurred monthly. During 
them even very little girls may lose all sense of modesty or decency. 
Every particle of self-control is gone. They are passionate, excitable, 
apparently possessed by the one uncontrollable desire to practise the 
habit. In the intervals such children may be quiet, modest, sweet-tem- 
pered, and perfectly normal. In some older subjects nymphomania, el- 
even insanity, may be the ultimate result. Epilepsy, chorea, ov hysteria 
may develop, particularly where a strong predisposition to them already 
exists in the family. The effect of masturbation upon the physical and 
mental development of the child may In' serious when it is begun at an 
early age or is frequently practised. P>ut even more striking is the 
change sometimes brought about in a child's moral nature. Even little 



692 DISEASES OF THE NERVOUS SYSTEM." 

children of eight or nine years may become centres of moral infection, 
which may involve a group of playmates or even a whole school. 

Loral symptoms of masturbation are nol always present; in the male 
there may he redness and slight swelling of the prepuce; the organs may 
he abnormally large or simply much relaxed. The frequent occurrence 
of erections in young children is always a suspicious symptom. In the 
female there is often seen an abnormal development of the genital organs 
for the age, with an early appearance of puhic hair. Xo importance is 
to he attached to adhesions of the clitoris. Sometimes there is vaginitis. 

Prognosis. — Masturbation in children is at all times a most difficult 
condition to deal with. The outlook is better in infants and young chil- 
dren than in those who are older, because the latter are more difficult to 
watch and control; besides, in them the habit has usually become more 
firmly fixed. In young children local causes are frequently found to be 
at the root of the trouble; in those who are older general causes are 
more often present, and these it may be impossible to remove. In almost 
any case in which the habit has become firmly developed, many months 
and usually several years are necessary for complete cure. The tendency 
to relapse is very strong. When masturbation is a symptom of degener- 
acy it is usually hopeless. 

Treatment. — The most important thing is an early recognition of 
the condition. The physician should put parents and. nurses on their 
guard, and the first suspicions should be reported and the child care- 
fully watched until all doubt is removed. In young infants much may 
be accomplished by mechanical restraint. The kind of restraint which 
is necessary will depend upon the manner of masturbating. If by the 
hands, they should be tied during sleep, so that the child can not reach 
the genitals; if by the thigh-friction, the thighs should be separated by 
tying one to either side of the crib. In inveterate cases, a double side- 
splint, such as is used in fracture of the femur, may be applied. In 
children that are over three years old, all such contrivances are almost 
invariably unsuccessful. It is of the utmost importance in every case to 
have the child under the close surveillance of a competent and trust- 
worthy person. He should be especially watched just after being put 
to bed and immediately after waking. Corporal punishment is often 
useful in very young children, but of little or no benefit in those who are 
over three years old. In fact, in such cases it may do positive harm, for 
deception and lying are soon added to the previous vice. The mother 
should secure the child's confidence, and in every way possible seek to 
strengthen his will and stimulate his self-control, using her influence to 
help him break the habit. The local causes, too, must be examined into 
and removed whenever found. Circumcision should be done if phimosis 
exists, and even when it does not, the moral effect of the operation is 
sometimes of very great benefit. In girls improvement sometimes fol- 



INJURIOUS HABITS OF l\!W<Y AM) CHILDHOOD. 603 

Iowa a separation under anaesthesia of the preputial hood from the 
clitoris. But unless this is frequently repeated, the adhesions soon recur. 
Complete circumcision is sometimes done with advantage, and in eery 
obstinate cases the clitoris ma\ be cauterised. Blistering the inside of 
the thighs, the vulva, or the prepuce is sometimes useful. Bui as a rule 
uone of these measures accomplishes anything permanent. Care should 

he taken that the clothing does not irritate the parts. The child should 

he removed from all vicious companions; hut it is quite as important 

that the greatesl vigilance should be exercised in the home and at school, 

so thai the child should have no opportunity to teach other children the 
habit. In the most serious cases the child should be senl away from 
home and kept from other children. The co-operation of a trustworthy 
nurse or companion is indispensable. General treatment should be di- 
rected to the child's condition; it is required in most of the cases 
child suffering from malnutrition and anaemia should be sent to the 
country, kept out of doors and away from hooks, studies, and from every- 
thing which stimulates or excites the nervous system. Almost all exer- 
cises except horseback may be recommended. Every means should he 
employed to build up the general health. These cases are most difficult 
and most discouraging ones for the physician. A cure results only In- 
using all these measures and for a long time. 

Nail-biting and tongue-sucking are two forms of habit which are less 
frequent and less important than those already mentioned. The former 
is best remedied by wearing gloves and by keeping the nails cut very 
short. Tongue-sucking seldom becomes a fixed habit, and the child usu- 
ally ceases it of his own accord as he grows older. 

Pica or perverted appetite is an inordinate desire to eat various sub- 
stances, such as dirt, sand, mortar or coal. It is most frequently 
in infants but may occur in older children. This habit is met with in 
those who are mentally defective, but not rarely in other children. 
These patients are usually highly neurotic and exhibit some of the other 
habits common to this class. In some children gastric derangements 
seem to play the part of an exciting cause. Pica is a common symptom 
of infection with hook-worm. The habit may continue for years unless 
corrected. The general health often becomes seriously undermined as 
a consequence of the disturbed digestion resulting from the presence 
of abnormal substances in the stomach. Children in whom such a 
habit is present should in the first place be watched and prevented from 
indulging in their abnormal craving. Secondly, the digestion and gen- 
eral health should be improved according to indications afforded by the 
individual case. 

Head-hanging is an expression of extreme nervous irritability most 
frequently seen in infants or in very young children. It is not indicative 
of any special form of nervous derangement, hut is caused by the same 



594 DISEASES OF THE NERVOUS SYSTEM. 

morbid impulse which leads other nervous children to scratch their faces, 
pull their hair, etc. While in some children head-banging occurs only 

onally, I have seen patients in whom it existed for a long time. 
It ma\ be repeated almosl every night, and continue at intervals for two 
or three hours, and that without temper or excitement, but with such 

as to produce contusions of the scalp and necessitate padding the 
sides of the crib. 1 1 is rarely a symptom of organic brain disease. 
Rickets is often associated and the nutrition of most of the patients 
is much below the normal. The treatment is general. 



CHAPTER III. 
DISEASES OF THE BRAIN AND MENINGES. 

MALFORMATIONS. 

Tin: malformations of the brain are of great variety, and many of 
them are solely of anatomical interest, as the conditions are incompatible 
with life. Only the most frequent and the best-known types will be men- 
tinned, and those which are of interest from a clinical point of view. 

Meningocele, Encephalocele, and Hydrencephalocele. — These three 
conditions have in common a protrusion of some part of the cranial con- 




Fk,. 106.— Meningocele. Fig. 107. — Encephalocele. Fig. 108. — Hydrenceph- 

alocele. 

through an opening in the skull. In meningocele (Figs. 106, 109) 
th<-n- j> protrusion of the membranes alone. These form a sac, which 
i- usually, hut not invariably, distended by fluid. In encephalocele (Fig. 
'"< ) ^><-i-<- is a protrusion of a portion of the brain substance; this is 
connected with the rest of the brain by a constricted neck or pedicle. 
The tumour may or may not contain fluid. In hydrencephalocele (Fig. 
there \a ;i protrusion of a portion of the brain substance which 
contains within it a cavity filled with fluid, this cavity communicating 
with the distended lateral ventricles. 

In mII these conditions there is a tumour, usually pedunculated, of 
a round or pyriform shape, with a smooth or lobulated surface. The 



MALFORMATIONS OF BRAIN AND MENINGES. 



695 



ordinary size is that of a mandarin orange; it may be as small as a 
walnut, or as large as the patient's head. It is generally covered by the 
scalp, which is often denuded of hair; but it may be covered only by 

granulation-tissue, or it may show 
a central cicatrix, like that of 
spina bifida. Other deformities, 
such as spina bifida, club-loot. and 
hare-lip are frequently present. 





Fig. 109. — Meningocele. From a patient in 
the Babies' Hospital. 



Fig. 110.— Frontal Meningocele. From 
a patient in the Babies' Hospital. 



All these conditions are rare, but the most frequent and most serious 
one is hydrencephalocele, this being usually associated with hydrocephalus. 
The next in frequency is encephalocele, which has the best prognosis. 
This is frequently termed hernia cerebri. If fluid is present, it is exter- 
nal to the brain. In meningocele (Fig. 109) there is simply an accumu- 
lation of fluid, which, communicates by a small opening with the general 
arachnoid cavity of the brain. 

Of 105 cases collected by Schatz, 59 occupied the occipital region 
and 46 were frontal. The aperture through which the occipital pro- 
trusion takes place is usually in the median line. It may communicate 
with the posterior fontanel, with the foramen 
magnum, or with the cleft of a spina bifida. 
The occipital bone may be divided in the me- 
dian line, or rarely it may be absent. 

In the naso-frontal form (Fig. Ill) the tu- 
mour is usually at the root of the nose, a little 
to one side of the median line. The aperture 
is most frequently between the cribriform plate 
of the ethmoid and the frontal bones. It may be 
between the lateral halves of the frontal bone, 
causing a median tumour. The point of pro- 
trusion may also be the lateral region of the skull, generally about 
the lateral fontanel, or along the line of the sutures; it may project 
into the mouth or the pharynx. These anterior tumours are usually 




Fig. 111. — Naso-frontal 
Meningocele. Infant 
one week old. 



DISEASES OF THE NERVOUS SYSTEM, 
small, although Large ones containing the anterior Lobes of the brain have 

91 I'M. 

The theory of the origin of those malformations which is most widely 
accepted is thai they are primarily cases of intra-uterine hydrocephalus, 
and as the cranial cavity is gradually closed by the development of the 
hones, a certain portion of the brain is left outside. 

Symptoms. The tumour is always congenital, although after birth 
it frequently increases very much in size. A typical tumour is round 
ami elastic, usually giving evidence of fluid; it pulsates synchronously 
with the heart ; during screaming or forced inspiration, it increases in 
partial and in some cases complete reduction is possible, but this is 
usually followed by marked cerebral symptoms, even by convulsions. 
After partial reduction, an opening in the skull may often be made out. 
Ificrocephalus may be present, or there may be unequal development of 
the two Bides of the head. 

The following differential points indicate the most characteristic 
feature- of the three varieties: In meningocele, the tumour is at first 
Bmall, hut increases; it has a smooth surface; it is pedunculated; there 
is distinct fluctuation, perfect translucency, rarely pulsation; often 
it is completely reducible; compression of the tumour causes cerebral 
symptoms; the skull is normal. In encephalocele, the tumour is small 
and smooth; jt is rarely pedunculated; fluctuation is absent; it is not 
translucent ; there is distinct pulsation; it is usually reducible; pressure 
causes cerebral symptoms; the skull is normal. In hydrencephalocele, 
there is a large pendulous tumour with an irregular or lobulated sur- 
face; it is pedunculated; translucency is rarely complete; fluctuation is 
distinct ; it is irreducible; pressure rarely causes symptoms; microcepha- 
lia and other deformities are often associated. 

The occipital tumours are usually more serious than the frontal ones. 
The majority of cases die in the course of the first few weeks of life, 
death resulting from meningitis, convulsions, or rupture. In menin- 
gocele the tumour usually grows slowly, and ultimately may be shut off 
from the cranial cavity; but gradual thinning of the membrane may take 
place, and spontaneous or accidental rupture occur. In encephalocele the 
rumour grows slightly, or not at all. Most of these patients exhibit signs 
of mental impairment or other evidences of organic brain disease. 

Treatment. — According to Treves, operation is justifiable only in 
case of impending rupture. The conditions present are essentially the 
same as in Bpina bifida. Meningocele may be aspirated or the sac may 
be laid open and a plastic operation performed for the closure of the 
communication with the cranial cavity; or the skin may be divided, and 
a ligature <>v clamp applied to shut off the communication with the 
brain. All these methods have been at times successful, but recovery 
D many instances been followed by the development of chronic 



MALFORMATIONS OF BRAIN AND MENINGES. 697 

hydrocephalus. Encephalocele is to be treated by protection and com- 
pression. Aspiration may be resorted to if fluid is present. In hydren- 
cephalocele the prognosis is absolutely bad under all circumstances. 
Schatz gives the following statistics, showing the results with and with- 
out operation, all varieties being included: Of twenty-four occipital 
tumours not operated on, three recovered ; of thirty-five operated on by 
excision, ligation, or injection, six recovered. Of forty-six frontal tu- 
mours, there were six recoveries in thirty-two cases without operation, 
and two recoveries in fourteen cases with operation. 

Microcephalus. — This is often regarded as due to premature ossi- 
fication of the skull; but the hypothesis is certainly inadequate to ex- 
plain all or even most of the cases. In many children suffering from 
marasmus, the sutures ossify and the fontanels close much earlier than 
in healthy infants of the same age, chiefly because, with the rest of the 
body, the brain also has ceased to grow. In microcephalus, I believe 
it usually to be the case that the early ossification of the skull is due 
to arrested growth of the brain, and not the reverse. The reasons for 
the developmental arrest in the brain are for the most part unknown. 

It is well known that there is not an invariable relation between the 
size of the head and the size of the brain, although generally the two 
correspond. If the circumference of the head is much below the average 
for the age (see introductory chapters), and relatively much less than 
the measurements of the rest of the body, microcephalus may be assumed 
to exist. Sachs calls attention to the fact that the circumference of the 
head may be nearly normal and yet the essential conditions of micro- 
cephalus exist, owing to imperfect development of the anterior part of 
the brain. 

The symptoms of microcephalus are those of mental deficiency and 
cerebral paralysis, existing in all possible combinations and with variable 
degrees of severity. 

The essential condition in microcephalus being an arrest in the devel- 
opment of the brain, it is not difficult to understand why the operation 
of craniectomy once thought so promising has been generally abandoned. 
The results do not justify any other operative measures yet proposed 
for the relief of these cases. 

Congenital Hydrocephalus. — These cases may fairly be considered as 
belonging in this group, although they are discussed elsewhere. 

Porencephalus (literally, a hole in the brain) is a condition in which 
there is a large depression in some part of the brain, but with surround- 
ing parts well developed. Such depressions may involve a whole lobe, 
and they may be deep enough to reach the lateral ventricles. 

Porencephalus is described as congenital or acquired. In the con- 
genital form, the defect is usually found in the anterior or middle part 
of the brain. The origin of these conditions is still a disputed question. 



D1S1 ^SES OF THE NERVOUS SYSTEM. 

are probably due to early vascular changes. Children sometimes 
veral years with very large defects, the symptoms depending upon 
;it of the lesion. The acquired form of porencephaly is usually 
one o( the late results of meningeal haemorrhage. It may affect one or 
both - - Such cases present the symptoms of spastic paralysis — 
usually diplegia. In all cases with large brain defects, the space is filled 
with fluid. 

PACHYMENINGITIS. 

Pachymeningitis, or inflammation of the dura mater, occurs both as 
an acute and a chronic disease. 

Acute Pachymeningitis. — This is very rare in children. Only pachy- 
meningitis externa is generally included under this term, as acute pachy- 
meningitis interna does not occur alone, but usually with inflammation 
of the pia mater (leptomeningitis). It may be associated with disease 
or injury of the hones of the skull, but is most frequently seen in con- 
nection with middle-ear disease. It generally begins as a localised proc- 
ess, but the inflammation may extend to the inner layer of the dura, 
and to the pia mater; or it may remain circumscribed, and terminate 
in the formation of an abscess between the dura mater and the bone. 

The symptoms of acute pachymeningitis are distinctive only when 
the process is localised. They are then usually associated with middle- 
ear disease, and are indistinguishable from those of cerebral abscess. 
The treatment is surgical. 

Chronic Pachymeningitis. — This, in children, almost invariably af- 
fects the inner layer of the dura mater (pachymeningitis interna) ; it is 
also known as pseudo-membranous and as licemorrhagic pachymeningitis 
or hcematoma of the dura mater. Its causes are for the most part un- 
known. It is a rather rare condition, being usually discovered at autopsy 
in children, chiefly cachectic infants, who have died of other diseases. 

Two classes of cases are to be distinguished — those with, and those 
without extensive haemorrhages. In the latter group there is found a 
thin, translucent, vascular membrane lining the inner surface of the 
dura. It may he only a delicate film which can be scraped off; it may be 
as thick as ordinary blotting-paper, or even twice that thickness. The 
membrane is often cedematous; it is exceedingly vascular, and the vessels 
have very thin walls. There are usually scattered punctate haemor- 
rhages, and there may be a few of larger size. This membrane may cover 
the whole inner surface of the dura, but in most cases it is principally 
the convexity and may be found only here; it is apt to be more 
upon one side than upon the other. In cases of long standing there may 
he adhesions between the dura and the pia. When large haemorrhages 
have taken place, quite a different pathological appearance is presented. 
The lesions found in a case upon which I made an autopsy in the New 



PACHYMENINGITIS. 609 

York Infant Asylum are fairly typical: The infanl was six months old, 

and the symptoms had existed for six days. The fontanel was bulging 
to a marked degree, and the sagittal and corona] sutures were separated. 
A thin recent clot from one-eighth to one-fourth of an inch in thickness 
covered nearly the whole of the right hemisphere and pail of the con- 
vexity of the left. The entire dura was lined both at its convexity and 
hase by a pseudo-membrane of grayish color, about one-sixteenth of an 
inch in thickness. The brain was anaemic. 

In cases of longer standing partial organisation of the clot may be 
seen; in more recent ones the blood is partly or entirely fluid. I once 
found acute leptomeningitis with a purulent exudation, associated with 
hemorrhagic pachymeningitis. In cases where life is prolonged for 
years, there may be partial or even complete absorption of the clot, 
followed by the formation of cysts, considerable inflammatory thicken- 
ing of the pia with deposits of blood pigment, and finally atrophy and 
sclerosis of the cortex. The source of the haemorrhage may be the rup- 
ture of a single large vessel, but more frequently the blood comes from 
many small vessels. 

Symptoms. — These are due to the haemorrhage, and not to the inflam- 
matory process. Until haemorrhage occurs there are no symptoms by 
which the disease can be recognised. Thus in many of the cases in which 
pachymeningitis is found at autopsy, its existence is not suspected dur- 
ing life. The occurrence of haemorrhage is sometimes marked by vomit- 
ing or convulsions, and usually there is loss of consciousness. It may 
be a question whether the convulsions are the cause or the result of 
the haemorrhage. In most cases they seem to be the result. They are 
usually general and repeated. If the haemorrhage occurs slowly, there 
may be stupor without convulsions until nearly the close of the disease. 
In the fatal cases the symptoms generally continue from two days to a 
week. There are dulness, stupor, and finally coma, death occurring in 
coma or convulsions. If the haemorrhage is diffuse — and this is apt to 
be the case — there is rigidity of all the extremities; if it is of one side 
only, the rigidity affects only one arm and leg. The pupils are more 
frequently contracted, but may be dilated or unequal. There is diplegia, 
hemiplegia, or monoplegia, according to the seat and extent of the 
haemorrhage. The respiration is slow and irregular and may he of the 
Cheyne-Stokes variety. The pulse is slow, irregular, and sometimes 
intermittent. The temperature is at first normal, but rises slowly until 
death occurs, when it is from 100° to 103° F. Generally the cranial 
nerves are not affected, and opisthotonus is absent. The knee-jerk is 
often exaggerated. In cases which do not prove fatal — these being chiefly 
in older children — we have a similar onset, but after a few days con- 
sciousness is regained, and only hemiplegia or monoplegia remains. 
The course of the paralysis is that seen after meningeal haemorrhage 



7(H) DIS1 \>l 38 OF THE NERVOUS SYSTEM. 

due to other causes. Wagner lias reported a case in which recurring 
lueiiiorrhagefl took place at intervals o\' several months, the autopsy 

iring distinct evidences of both old and recent lesions. 

Pachymeningitis, I am inclined to believe, plays a much more im- 
portant role in the production of meningeal haemorrhages in children 
than has generally been accorded to it. From the frequency with which 
this lesion is found as a cause o\' sudden meningeal haemorrhages which 
arc fatal, it is not unlikely that some of the cases which recover with hemi- 
plegia or monoplegia, may be due to the same cause. 

The prognosis depends upon the age of the patient and the extent of 
the haemorrhage. Extensive haemorrhages are usually fatal in infancy, 
hut small ones are seldom so, for they are rarely at the base. The prog- 
Qosis of the paralysis in cases not terminating fatally is the same as 
after meningeal haemorrhage due to other causes, with perhaps an added 
liability to recurrent attacks. 

Without large haemorrhages, pachymeningitis interna can not be 
diagnosticated; and it is impossible to differentiate the hemorrhagic 
from other varieties of meningeal haemorrhage. It is important to 
make a diagnosis between pachymeningitis with haemorrhage, and acute 
simple meningitis. In the former there is a sudden onset; stupor oc- 
curring early, usually on the first day, gradually diminishing in cases of 
recovery, or deepening into coma in fatal cases; localised or general 
paralysis, also occurring early; there is no fever in the beginning, and 
only moderate fever at the close. In acute meningitis there is usually 
a higher temperature, especially early in the disease; coma develops 
later, and rigidity of the extremities is less pronounced. In certain 
however, when the haemorrhage occurs in the course of some other 
disease, a differential diagnosis may be impossible. 

Treatment. — The treatment of pachymeningitis haemorrhagica is 
symptomatic. The indications are, to relieve cerebral congestion by 
applying ice to the head, to allay irritative symptoms by the use of 
bromides, and to keep the patient perfectly quiet. 

ACUTE MENINGITIS. 

eral different varieties of acute meningitis are met with in chil- 
dren. Cerebrospinal meningitis is the only form which occurs epidem- 
ically: but this is also seen as a sporadic disease. It is due to a specific 
organism, the meningococcus. There are several other forms of acute 
meningitis which more or less closely resemble cerebro-spinal meningitis 
clinically, and which were for a long time confounded with it. Pneu- 
mococcus and influenza meningitis are usually secondary inflammations, 
but sometimes are apparently primary. The typhoid bacillus and the 
gonococens may cause acute meningitis, but very rarely in children. 



CEREBRO-SPINAL MENINGITIS. 701 

Acute meningitis may be due to any of the pyogenic organisms. This 

is sometimes spoken of as " septic " meningitis, and is almosl invariably 
secondary. Finally, there is tuberculous meningitis, altogether the most 
common variety in young children except during epidemics of cerebro- 
spinal meningitis. 

Some idea of the relative frequency of the different forms of acute 
meningitis as seen apart from epidemics, may be gained from the fol- 
lowing figures which give the number of cases occurring in the Babies' 
Hospital for a series of years, the diagnosis in every case being made by 
lumbar puncture or by autopsy. The patients were nearly all under 
three years of age. The organism found was as follows: 

Tubercle bacillus 157 

Pneumococcus 23 

Meningococcus (sporadic) 24 

Staphylococcus or streptococcus 11 

Influenza bacillus 5 

Colon bacillus 1 



CEREBRO-SPINAL MENINGITIS. 

(Epidemic Meningitis; Cerebrospinal Fever.) 

Epidemics of cerebro-spinal meningitis are separated by quite long 
intervals and occur without any assignable cause. The following chart 
(Fig. 112) represents the prevalence of the disease in New York City 
during forty years. But little was seen of cerebro-spinal meningitis until 
the epidemic of 1872. Since that time a certain number of deaths from 





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Fig. 112. — Chart showing Deaths from Cerebro-spinal Meningitis in New York 
City, for Forty Years, per 100,000 of Population. 



this cause have occurred each year; but there have been seen about once 
in ten years epidemics of greater or less severity. The most important 
one was that of 1904-5. After each epidemic, for two or three years, 
the disease is prevalent, but it occurs with gradually lessening frequency 
until the average incidence is reached. What has been said of New 



MS! \>is OF THE NERVOUS SYSTEM. 

York i> true o\ almost every large city. In remote country towns, 
epidemics are occasionall) witnessed, and alter prevailing a lew months 
the disease disappears as mysteriously as it came. Epidemics are usually 
Been in the winter and early spring, lasting for several months, gen- 
erally reaching their heighl in March or April and slowly subsiding as 
warm weather approaches. 

With reference to the cause of epidemics very little is known. When 
the disease prevails in cities it occurs especially in crowded tenements, 
being relatively infrequenl in private houses. 

Cerebrospinal meningitis has only recently been included among 
the communicable diseases. In a series of observations made by the 
New York Health Department the meningococcus was found in the 
nasal secretion of fifty per cent of the cases of meningitis examined 
during the first two weeks of the disease. It was found in the nasal 
mucus in ten per cent of the persons in close contact with cases. In 
Flexner's experiments upon monkeys he found the organism in the nasal 
mucus after animals had been inoculated by way of the spinal canal. 
These observations indicate that the nasal mucosa is a common avenue of 
infection and probably also a channel of elimination. The degree of 
communicability when compared with the common contagious diseases 
seems very slight. In fully seventy per cent of the cases investigated 
in the New Y'ork epidemic of 1904-5, but one person in a household was 
affected, although no effort at isolation was made. I have never known 
the disease to originate in a hospital patient, although in New York 
>f cerebro-spinal meningitis have been until very recently received 
into the general wards with other patients. Sporadic cases of menin- 
gitis occur after epidemics, and quite apart from them without apparent 
cause, and it is very exceptional that any connection with a previous 
can be established. About fifty per cent of the cases of cerebro- 
spinal meningitis occur in children under five years, and about twelve 
per cent in those under one year. The youngest case I have seen was 
in an infant six weeks old. 

The specific organism of cerebro-spinal meningitis is the diplococcus 
intracellulars of Weichselbaum or, as it is now generally designated, 
the meningococcus. It is present in the meningeal exudate, in the 
cerebro-spinal fluid obtained by lumbar puncture, and in some cases can 
be demonstrated in the blood, the lungs, and other organs, sometimes 
in the large joints. Ii is almost invariably found in pairs or tetrads 
within the leucocytes. It is decolourised when stained by Gram's method. 
Outside the body the organism is unknown. 

Lesions. — In epidemic meningitis death may take place so early that 
the changes found al autopsy are slight. There may be only a serous 
exudation and intense hyperemia, which is doubtless much less marked 
niter death than during life. The cerebro-spinal fluid is turbid and 



CEREBROSPINAL MENINGITIS. 703 

much increased in amount. The microscope, however, may show, even 
in these early cases, an abundant exudation of leucocytes in the pia 
mater. After the third day the lesions are quite uniform. The con- 
volutions appear somewhat flattened from pressure due to distention of 
the ventricles. The inner surface of the dura is usually normal or only 
congested. There may be thrombi in any of the cerebral sinuses, or in 
the meningeal veins of the convexity. There is an exudation of greenish- 
yellow fibrin, which is sometimes very abundant. It is generally widely 
distributed, but is most marked over the anterior half of the brain and 
at the base. In some cases it is limited to the base, but very rarely 
limited to the convexity. There is an increase in the quantity of cerebro- 
spinal fluid. The ventricles are moderately distended with serum or 
sero-pus, and their walls may be slightly softened. The brain substance 
of the cortex may be reddened or may appear normal. In the meninges 
of the cord, lesions similar to those of the brain are usually seen. The 
exudation is principally upon the posterior surface, and may extend 
throughout the entire length of the cord, or be limited to its upper or 
to its lower portion. 

Microscopical examination shows the exudation to consist of fibrin 
and pus cells, which infiltrate the pia mater. The superficial layers of 
the cortex in the inflamed areas often show minute hemorrhages and 
very marked cell-infiltration. Minute abscesses may be present. Very 
marked degenerative changes can usually be demonstrated in the nerve 
cells themselves. The cells of the neuroglia are also affected; they are 
swollen and increased in number; and there may be proliferation of the 
connective tissue about the blood vessels. Changes similar to those just 
described may be found in the cord, but these are less frequent and as 
a rule much less severe than those in the brain. Inflammatory products 
are sometimes present in the central canal of the cord and in the walls 
of the lateral ventricles of the brain. The inflammatory process fre- 
quently extends along the cranial nerves, especially the auditory and 
optic, and this may result in otitis or choroiditis ; from the cord, it may 
extend along either the anterior or posterior nerve roots. Descending 
degeneration is found in the nerves both of the brain and cord. 

In patients that die after the disease has lasted two or three months, 
the later results of these lesions may be seen. There is usually present a 
chronic meningo-encephalitis, sometimes diffuse, sometimes localised. 
The pia mater is cloudy, thickened, and frequently adherent to the 
brain. Here and there are seen small, yellow, opaque patches which are 
the result of fatty changes in the cells and fibrin of the exudate, with 
some proliferation of connective tissue. The lesions are usually most 
marked at the base, where the thickening of the meninges and the ad- 
hesions may lead to the development of a secondary hydrocephalus. 

In cases which have lasted a much longer time the most marked 



701 DISEASES OV THE NERVOUS SYSTEM. 

changes are in the brain Bubstance. There may be generalised menin- 
geal adhesions, 1 with a diffuse cortical atrophy, but more frequently there 
are areas of sclerosis, especially over the frontal and temporo-sphenoidal 
lobes, with which there are almost always associated marked descending 
degenerative changes in the cord. Such lesions are, of course, perma- 
nent, and seriously interfere not only with the functions, but also with 
the growth and development of the brain. 

The visceral lesions most frequently found in epidemic meningitis 
are pulmonary. There may be lobar or broncho-pneumonia, and in the 
lungs may he found the same organism as in the brain. Acute de- 
feneration of the liver and kidneys is also frequent. The other viscera 
are seldom affected. Occasionally suppurative inflammation of the joints 
occurs. 

Symptoms. — The symptoms of cerebro-spinal meningitis do not differ 
essentially in the sporadic and epidemic cases, except that the most 
severe forms of the disease are seen in the latter. They may be divided 
into several quite distinct groups: 

1. Hyper-acute Form. — Cases of this kind are rarely seen except in 
an epidemic, and usually occur at its height. The onset is very abrupt, 
the course short and intense, and death may take place in from twelve 
to thirty-six hours. The following case illustrates this type: A little 
girl of ten years was well enough at 2 p.m. to carry a bundle of clothes 
a dozen city blocks. Eeturning home, she complained of intense head- 
aehe, vomited frequently, and was so weak that she was obliged to go to 
bed. In a few hours she passed into deep coma, with very high fever, 
and died at 11 p.m. 

The earliest pymptoms are usually intense headache, repeated attacks 
of vomiting, and very high fever. There is great prostration and the 
nervous symptoms increase so rapidly that in a few hours the patient 
may become comatose and death occur in a short period. The tempera- 
ture rises rapidly to 103° or 104°, sometimes to 106° F. A few petechial 
spots may be discovered over the face, chest, or extremities. There is 
usually no rigidity, but rather general relaxation. The pulse is weak, 
in mosl eases rapid, but sometimes slow and irregular. The respiration 
i- usually irregular both in frequency and depth. 

1 This lesion and its effects are well illustrated by one of my own patients who 
died six rnoril lis after an attack. She was a bright little girl of four and a half years, 
and had a typical attack of meningitis of moderate severity. Convalescence was 
alow, bu1 at t be end of two months recovery was perfect in everything but her mental 
cowl it ion. She remembered nothing which she had previously learned in the kinder- 
garten, where she had been an exceptionally bright pupil Her mind was a blank. 
She was dull, listless, and her face had a vacant, idiotic expression. The special 
'•fined unaffected, and her speech was retained. She died during an attack 
of convulsions. At the autopsy the pia was everywhere thickened and adherent, 
while in the cortex were present the earlier changes of a general encephalitis. 



CEREBllO SPINAL MENINCJ1TIS. 



705 



The symptoms appear to be due to two factors: First, the intensity 
of the infection; second, the rapid accumulation of cerebrospinal fluid, 
causing coma with cardiac and respiratory paralysis. Usually both 
these factors are present, but I believe that the second one is the more 
important. In support of this view is the striking infrequency of cases 
of this type in infants with an open fontanel. Should the patient sur- 
vive the violence of the onset, a period of reaction occurs, and after a 
day or two the disease follows the regular course. 

2. Usual Form. — In this also the onset is generally abrupt, but not 
so violent as in the cases just described. It may be marked by intense 
headache, vomiting, convulsions, delirium, chills, and fever with general 
hyperesthesia and rigidity. The initial temperature is from 101° to 
104° F. Opisthotonus, with severe pains in the back of the neck and 
along the spine, and general muscular rigidity are usually present. 
There is often active delirium, but rarely stupor or coma. The pulse 
is generally rapid, 120 to 150, and sometimes irregular. The respira- 
tion is often slightly irregular, and it may be rapid or slow. The erup- 
tion is not so frequently seen as in the very acute cases. 

As the disease progresses, the nervous symptoms often change but 
little from day to day for two or three weeks. They are mainly of the 




Fig. 113. — Posture in Cerebrospinal Meningitis. (Smith.) 



irritative type — moderate delirium, extreme hyperesthesia, tremor and 
muscular rigidity. The posture is quite characteristic (Fig. 113). 
Owing to the opisthotonus the child can not lie upon the back, but rests 
upon the side, with arched spine and neck, and general flexion of the 
extremities. There is a rather rapid loss in weight, steadily increasing 
prostration, and a weak, rapid pulse. The bowels are usually constipated. 
From time to time attacks of vomiting occur. In most cases there is 
considerable difficulty in feeding. The duration of this form of the dis- 
ease is from three to six weeks. The course is often marked by periods 
of remission and exacerbation. If recovery is to take place, the tem- 
46 



70o DISEASES OV THE NERVOUS SYSTEM. 

perature gradually falls to Dormal and often at times it is subnormal. 
The mind becomes clear, and one by one (he nervous symptoms dis- 
appear, the muscular rigidity being usually the last to go. Convalescence 
18 always protracted. 

In cases ending fatally, the patient usually passes into a deep stupor 
en- coma, with extreme prostration, a slow, weak, irregular pulse, shallow 
respiration of the Cheyne- Stokes variety, sunken abdomen, general re- 
laxation, and death occurs from exhaustion or from broncho-pneumonia. 

Occasionally the attack is much prolonged, the fever and all the 
active symptoms continuing from eight to twelve weeks. Emaciation 
sometimes becomes extreme, and with a few nervous symptoms may con- 
tinue long after the fever ceases. In infants, death is often due to 
marasmus. While a fatal outcome is more frequent in these prolonged 
not a few recover completely, even when s}^mptoms have lasted 
for eight or ten weeks. 

Mild Form. — Especially toward the end of an epidemic, and some- 
times occurring sporadically, there are seen cases which in their onset 
and for the first two or three days resemble those just described; but 
instead of running the usual course, the fever and the nervous symptoms 
subside rapidly and convalescence is established early. 

4. Chronic Form. — Owing sometimes to the extent, sometimes to the 
position of the lesions, the disease does not subside at the usual time, 
but nervous symptoms continue after the temperature and most of the 
other constitutional symptoms have passed away. These cases are chiefly 
of the basilar type, and often lead to the development of chronic basilar 
meningitis with secondary hydrocephalus. They are more fully con- 
sidered in a later chapter. 

Onset. — One of the most striking features of this disease is the ab- 
ruptness with which it develops. Occasionally there are indefinite symp- 
toms for a day or two before active symptoms begin; but in the great 
majority not only the day, but the hour of the onset is definitely marked. 
The most frequent initial symptoms are the simultaneous occurrence of 
severe headache and vomiting, followed by high fever and marked pros- 
tration. The vomiting is usually repeated, projectile, and has no relation 
to meals. Convulsions occurred in the beginning of thirty per cent of 
my cases. Occasionally a decided chill is seen. After twenty-four hours 
acute general pains and hyperesthesia are usually present, together with 
rigidity of the muscles of the neck and extremities, giving rise to opis- 
thotonus and muscular contractions. 

8hin. — Eruptions upon the skin vary much in frequency in different 

and in different epidemics. The most characteristic one is the 

appearance of small punctate haemorrhages, resembling flea bites; they 

are not numerous, but may be found on almost any part of the body, 

most frequently upon the extremities, the upper part of the chest, and 



CEREBRO-SPINAL MENINGITIS. 707 

neck. In my experience they have been present in about fourteen per 
cent of the cases. Sometimes larger haemorrhages are present. From 
this symptom the name "spotted fever" has arisen. This petechial 
eruption belongs to the early stage of the disease, fades quickly, and is 
rarely visible after the third or fourth day. In some cases a general 
erythema is present; in others, an eruption closely resembling measles. 
Herpes upon the lips and face is common in older children, but is rare 
in infants. Bed-sores have been seen in about one-third of my cae 
They are found over pressure points — the trochanter, the malleoli, and 
the side of the head; in several instances the ear has been the part 
affected. 

Nervous System. — Headache is a frequent initial symptom and is 
usually severe ; it is more often frontal than elsewhere, and may be asso- 
ciated with vertigo. There are acute pains in the back of the neck, along 
the spine, and marked general hyperesthesia, which is often so intense 
that any movement of the body causes agonising cries. This is one of 
the most striking symptoms of the disease, and may continue throughout 
the acute stage. The mental state varies much in different cases. De- 
lirium is frequent in the early stage of the severe form; it is usually 
wild and active. After delirium a stage of dulness or apathy ensues, 
giving place to great irritability when the patient is disturbed. Con- 
vulsions are sometimes seen early, but are seldom repeated in the course 
of the disease or toward its close. There is rarely continuous or deep 
coma except toward the end of fatal cases. In some cases with high tem- 
perature and quite severe symptoms, after the subsidence of a short 
early stage of excitement or delirium, the mind remains perfectly clear 
throughout the attack. Under these circumstances an erroneous diag- 
nosis is often made, particularly if the physician has not observed the 
case from the beginning. 

Tonic spasm of the various muscular groups is one of the most char- 
acteristic features of this disease and is seldom absent. Like the hyper- 
assthesia it is persistent. The rigidity and contraction of the muscles 
of the neck and back produce cervical or general opisthotonus; cervical 
opisthotonus is most marked with lesions chiefly at the base, and may 
be wanting in the rare cases when the lesion is almost entirely at the 
convexity. Tonic spasm of the extremities usually causes general flexion 
of the thighs, legs, and arms. Late in the disease this may be replaced 
by complete extension of the lower extremities with dropping of the 
feet. The tonic muscular spasm gives rise to Kernig's sign, viz., inabil- 
ity to extend the leg when the thigh is flexed upon the body. In young 
children one should not place too much dependence upon this sign. 
While rarely wanting in cerebro-spinal meningitis, it is often present 
in other conditions. Muscular rigidity is one of the most common symp- 
toms and one of the last to disappear. It may be absent in the early 






DISEASES OF THE NERVOUS SYSTEM. 



of the hyper-acute cases, and very Late in fatal cases, when there 
inav be general relaxation. Other nervous symptoms frequently present 
are ankle clonus, muscular tremor, especially of the hands, and paralysis, 
which may be facial, monoplegia or hemiplegic. Early in the disease 
the knee-jerks are usually increased; in the later stages they are often 

Eye and Ear. — The pupils in the early stage are generally contracted; 
toward the close they are usually widely dilated. Ocular paralyses are 
not so frequent nor so marked as in tuberculous meningitis. The same 
is true o( the changes in the optic disc, although these vary much in 
different epidemics. There may be congestion of the fundus, retinitis, 
or optic neuritis. In some epidemics such changes have been observed 
in fully half the cases. In that of 1904r-5, in my own hospital cases, 
they were rarely seen, and then were but slightly marked. Conjunctivitis 
is frequently present and may be severe. There may be choroiditis 
and sometimes complete destruction of the eye, but usually this is uni- 
lateral. In most epidemics the ears are more frequently affected than 
the eyes. Early deafness may be due to a lesion of the auditory nerve, 
is generally bilateral, and often permanent. Acute otitis media occurs 
as a complication, and the meningococcus is occasionally found in the 
discharge. This was true of three of my hospital cases. Permanent 
deafness is sometimes due to changes in the brain itself. 



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Fig. 114. — Cerebro-spinal Meningitis. Recovery. Fairly typical chart of prolonged 
case, showing remissions and exacerbations. Private patient, three and a half years 
old; unconscious, blind, and deaf for two and a half months; complete recovery. 



Fever.— Tim disease is usually attended by high fever, but the curve 
is apt to be an irregular one and show wide variations. The tempera- 
ture is nearly always high at the onset; in the hyper-acute cases it may 



CEREBRO-SPINAL MENINGITIS. 709 

reach 106° F. or higher. The usual range during the disease is from 
100° to 105° F. (Fig. 111). Sometimes it is steadily high; not in- 
frequently a few days after a sharp acute onset it falls nearly or quite 
to normal and remains there for several days. Cases seen in this afebrile 
period are most difficult of diagnosis. This stage may be followed by 
another sharp rise, and afterward continuous fever. Periods of remis- 
sion and exacerbation in the temperature are seen in a large proportion 
of the prolonged cases. Often it becomes subnormal. The temperature 
may bear no relation to the severity of the other symptoms. Its course 
is greatly modified by the serum treatment. 

Respiration is disturbed very early in the disease, when it is often 
irregular and may be slow or rapid. Throughout the greater part of 
the attack it may be nearly normal. Occasionally it is of the typical 
Cheyne- Stokes variety. 

Pulse. — Throughout the greater part of the disease the pulse is rapid. 
In the early stage it is often weak, and sometimes irregular. The average 
frequency in young children is from 130 to 150. A slow, irregular pulse 
is occasionally seen late in the disease in patients who are in deep coma. 

Blood. — A leucocytosis is present in nearly all cases. The average 
is from 15,000 to 30,000. The increase is chiefly in the polymorpho- 
nuclear cells. Blood cultures made early in the disease have in some 
cases shown the presence of the characteristic organism. 

Digestive System. — Vomiting is one of the most frequent symptoms 
of onset but rarely persists throughout the attack. Late in the disease, 
it may be most troublesome. As a rule constipation is present. The 
tongue is coated, dry, glazed, sometimes covered with sordes. In a small 
proportion of cases jaundice has been observed. On account of the loss 
of appetite, great irritability, delirium, and stupor, the greatest difficulty 
is often experienced in feeding these patients. In young children gavage 
is much more satisfactory than rectal feeding. Early in the disease 
the abdomen is natural. In the late stage it is often very much re- 
tracted. 

General Nutrition. — This is impaired in nearly all cases. There is a 
progressive wasting, greater than would be explained by the disturbance 
of digestion. In the protracted cases it may be extreme. Infants and 
young children often die of inanition or marasmus long after the active 
symptoms of the disease have subsided. 

Other symptoms of importance are the tense, bulging fontanel, in 
infants rarely absent early in the attack, but often wanting in the late 
wasting stage; incontinence of urine and faeces, and retention of urine, 
very frequent and often overlooked; occasionally swelling of some one 
of the large joints is seen. 

Course, Duration, and Termination. — Excluding the fulminating cases 
in which death occurs very early, the usual duration of active symptoms 



710 DISEASES OF THE NERVOUS SYSTEM. 

in cases not treated with serum is from three to six weeks. Of 350 cases 
ring without Berum, the disease lasted less than one week in three 
per cenl : in fifty per cenl it was five weeks or longer. Some very pro- 
tracted cases terminate favourably. I have seen one child recover com- 
pletely after 84 days oi' fever, and another after 102 days. Most of the 
prolonged rases are marked by periods of exacerbation and remission. 
Not until the temperature has been normal for several days, the mind 
has become clear, and the hyperaesthesia and rigidity have entirely disap- 
peared, can we consider convalescence as established. Recovery is slow, 
and it may he many months before the child is quite well. In 220 cases 
receiving serum treatment the average duration of active symptoms after 
the first injection was 11 days. 

In fatal cases, death may come early from coma, convulsions, or 
heart failure. It may occur in the middle period from complications, 
most frequently pneumonia, or the terminal stage of the disease may be 
seen with extreme wasting, and finally death from exhaustion. • 

Complications and Sequelae. — The chief ones are pneumonia, otitis, 
conjunctivitis or choroiditis, and bed-sores. Rarely, nephritis and arthri- 
tis are seen. Sequelae are, unfortunately, very common. There may 
be perfect recovery so far as physical functions are concerned, but the 
child be left mentally deficient. In some cases the defect is so slight 
as not to be evident for several months or even 3^ears; in others the 
mental faculties are entirely lost. There may also be various types of 
paralysis — strabismus, facial paralysis, monoplegia, hemiplegia or diple- 
gia, and often contractures, which are sometimes temporary, but apt to 
be permanent. The acute attack may be followed by chronic meningitis 
with hydrocephalus. Deafness is quite common, usually of both ears, 
and deaf-mutism is not an infrequent result in young children. Blind- 
ness is not so common and is usually unilateral. As a late result epilepsy 
may develop. 

Prognosis. — The mortality is usually higher in epidemics than when 
the disease occurs sporadically. It is usually greater at the height of 
an epidemic and lower at its close. The average mortality before the 
serum treatment was about 70 per cent. I know of no epidemic on 
record in which the mortality was less than 50 per cent. In the last year 
(1905) of the New York epidemic, of 1,780 cases tabulated by the De- 
partment of Health the mortality was 76 per cent. Of 59 cases treated 
in my hospital wards in the same epidemic the mortality was 80 per 
cent, nearly all these patients being under three years of age. Of 24 
under one year only one recovered. Of the cases I saw in private 
practice, largely older children, the mortality was 50 per cent. Not all 
of those who do not die are to be classed as recoveries, for in fully 25 per 
cent serious sequelae remain. The results with Flexner's serum are re- 
ferred to under Treatment. 



CEREBRO-SPINAL MENINGITIS. 711 

Diagnosis. — Lumbar puncture is the only accurate means of diagnosis 
we possess. By it we can not only differentiate meningitis from other 
diseases with nervous symptoms, but can distinguish this from other 
varieties of meningitis. Furthermore, this is possible very early in the 
disease. With proper precautions I believe it to be practically free from 
danger, and it should be employed whenever meningitis is suspected. 
The procedure is not difficult, but the technique is important. 1 The 
quantity of fluid which may be removed at one time varies from a few 
drops to three or four ounces. During the first day or two it is usually 
a slightly cloudy or turbid serum; sometimes it is thick and purulent. 
As the disease progresses the pus cells gradually diminish, and in favour- 
able cases disappear, but may reappear with an exacerbation of the symp- 
toms. These changes are much modified by serum injections. 

The presence of many leucocytes in the cerebro-spinal fluid indicates 
meningitis, which may be due to the meningococcus, but also to the 
pneumococcus, the influenza bacillus, the staphylococcus, or the strepto- 
coccus. The variety can be determined only by microscopical examina- 
tion of stained smears from the sediment of the fluid obtained after 
standing or after centrifuging, and by cultures, which should be made 
immediately after the fluid is withdrawn. In cerebro-spinal meningitis 
diplococci are found within the pus cells and some are also free in the 
fluid. The organisms are usually numerous. 

The diagnostic value of lumbar puncture, when properly performed, 
is very great ; not only are positive findings conclusive, but early negative 
findings almost certainly exclude meningitis. I have met with two ex- 
ceptional cases in which early punctures gave a clear fluid and no organ- 

1 Puncture may be made with an ordinary surgical exploring needle, but the spe- 
cial lumbar needle devised by Quincke is preferable. This is merely a fine trocar and 
cannula and is made somewhat stronger than an exploring needle, which sometimes 
breaks. The child is placed upon the right side with the thighs tightly flexed against 
the abdomen to separate the spines and laminae of the vertebrae as much as possible. 
The point chosen for puncture is in the median line between the third and fourth 
lumbar vertebrae. This is on a level with the highest part of the iliac crest. The 
strictest asepsis is required. The skin should be carefully cleansed and the needle 
boiled. The pain is no greater than from exploratory punctures elsewhere. No 
anaesthetic is necessary for infants, but sometimes is required for older and especially 
sensitive or nervous children unless they are comatose. Local anaesthesia may be 
employed or a few whiffs of chloroform given, but always with caution, for the com- 
bined shock of the puncture and the chloroform is sometimes considerable. The 
child should be closely watched for at least fifteen minutes after the puncture is made. 
The canal is reached at the depth of about one inch. The trocar is now withdrawn 
and the fluid usually flows freely through the cannula, sometimes spurting forth some 
distance, owing to high pressure. A dry puncture is generally due to the fact that 
the canal has not been entered; sometimes that the exudate is too thick to flow 
through the small needle, or that the needle has been plugged. Raising the patient 
to a sitting posture usually causes a freer flow, as does also flexing the head upon the 
chest if opisthotonus is extreme. 



71 -j DISEASES OF THE NERVOUS SYSTEM. 

isms were found ; a few days later the fluid was turbid and organisms 

abundant. The meningococcus may persist for a long time. In 

one of my rases not treated by serum it was present on the ninetieth day. 

The diagnosis o( cerebrospinal meningitis by symptoms alone presents 
peculiar difficulties at the beginning of the attack. The most valuable 
early Bymptoms for diagnosis are. a sudden onset with intense headache, 
vomiting, high temperature, prostration, the petechial eruption, marked 
rigidity of the neck and extremities, with hyperesthesia, great irritability 
or early stupor, even coma. Later, three symptoms are rarely wanting — 
stent hyperaesthesia, muscular rigidity of the neck and extremities, 
and fever. Kernig's sign is seen in other conditions and is not diagnostic. 
-:>inal symptoms are more to be relied upon for diagnosis than are 
the cerebral symptoms. The mind in some cases remains perfectly clear; 
in others there is delirium, but seldom continuous, deep coma. 

At its beginning, cerebro-spinal meningitis may be confounded with 
pneumonia or other diseases with cerebral symptoms. It is differentiated 
with certainty only by lumbar puncture. It is sometimes difficult to 
distinguish between cerebro-spinal and tuberculous meningitis. The 
former is relatively infrequent except in epidemics. The fluid in cere- 
brospinal meningitis is usually turbid and contains many cells of the 
polymorphonuclear variety; in tuberculous meningitis the fluid is gen- 
erally clear and the few cells found are lymphocytes. Tuberculous 
meningitis may occur anywhere or at any time. Its characteristics are 
a gradual onset with indefinite symptoms, low temperature, drowsiness, 
irregularity of pulse and respiration, absence of active delirium, late 
coma, less marked hyperesthesia and rigidity, duration seldom over three 
a from the beginning of definite cerebral symptoms, termination in- 
variably fatal. Cerebro-spinal meningitis, however, frequently ends in 
recovery, and it is the only form of acute meningitis which does so. 

Treatment. — Flexner of the Eockefeller Institute has developed a 
serum for the treatment of cerebro-spinal meningitis which has been 
shown to be more effective in controlling the disease than any other 
measure thus far proposed. The serum is obtained by immunising horses 
with toxins and cultures obtained from many strains of the meningo- 
coccus. It acts chiefly on the bacteria themselves, and only to a slight 
on their products; i.e., it is a bacteriolytic serum. It is used as 
follows: After withdrawing by lumbar puncture all the fluid that will 
flow readily, under the strictest aseptic precautions, the serum, warmed 
to the body temperature, is injected without removing the needle. In 
some exceedingly sensitive patients the administration of a few whiffs 
of chloroform may be necessary. The injection should be made very 
slowly, occupying several minutes. Raising the hips facilitates the inflow 
of the serum. To be effective, it must be brought into contact with the 
isms in the spinal canal in a considerable degree of concentration. 



CEREBRO-SPINAL MENINGITIS. 713 

The initial dose is 30 to 40 c.cm., which should be repeated in twelve 
hours if there is no improvement in the symptoms. Usually the second 
dose is not given until the end of twenty-four hours, and after that a 
daily dose of the same size for four or five days should be given, unless 
there is a prompt disappearance of all symptoms. Injections should be 
continued so long as organisms are found in the fluid or nervous symp- 
toms, fever, and leucocytosis persist. If done cautiously, it is safe to in- 
troduce more serum than the amount of fluid withdrawn. In the milder 
cases it sometimes happens that a single dose may suffice for a cure ; but 
even under such circumstances it is safer to give at least three doses. 
The serum arrests the inflammatory process by destroying the organisms 
which produce it. To accomplish this a sufficient dose must be given, 
and given early, before important inflammatory changes have taken place. 

An immediate effect of the injection is seen in the cerebro-spinal 
fluid. There is a marked reduction in the percentage of polymorpho- 
nuclear cells. The number of meningococci is greatly reduced and their 
vitality lessened. After the first injection they stain with difficulty, and 
after a second injection it is generally impossible to grow them, although 
they are usually present in small numbers (Fig. 115). The effect on the 
symptoms is striking. There is a marked reduction in the temperature, 
which may amount to three or four degrees in twenty-four hours, and it 
may not rise again (Fig. 116). The stupor and delirium often diminish 
rapidly, and soon disappear. Improvement is also seen in the patient's 
general condition, pulse, and respiration. The last symptoms to be 
affected are usually the rigidity of the neck and extremities. 

The results of this treatment show a much larger percentage of re- 
coveries than has been obtained by any other method. 1 Of 1,500 cases 
of all types, in patients of all ages, thus far treated by this serum, the 
general mortality was about 25 per cent. The figures represent results 
obtained in many epidemics in all parts of the world. The statistics from 
this country are not so favourable as those from abroad with the same 
serum, for the reason that in the results here are included reports from 
many physicians who, without experience in the use of the serum, treated 
but one or two cases. The foreign statistics, however, are in larger 
groups, and the cases for the most part were under the care of men who 
had had experience with the serum. In the recent epidemic in France 
the mortality of the cases not treated by serum was about 70 per cent, 
while in those receiving serum it was but 15 per cent. This indicates 
what may be expected with serum treatment under favourable conditions. 
One of the most striking evidences of the value of this treatment is the 
results obtained in infants under one year. Without serum these cases 

1 For details, see articles by Flexner and his associates in the Journal of Experi- 
mental Medicine, from September, 1908, to 1911. The serum can be obtained from 
the New York Health Department. 



714 



DISEASES OF THE NERVOUS SYSTEM. 



Day 
IM° 

103" 

102 c 


2 


3 


4 


5 


6 


7 


8 


9 


10 










/ 


f- 




L 


* 


2 


\ 


/ 


/ 


J 


I 


-J 


£ 










4 


V 








- 








101 ■ 
100° 
99 c 

98 ° 


v 


w 


/ 


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s 
















\ 


t 


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i 


5 




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A 


I- 






















































S 


— 


























































































































Day 


2 


3 


4 


5 


6 


7 


8 


9 


10 


Leucocytes 




20,400 


25,600 


15,000 


16,400 


16,000 


12,500 


21,000 


20,000 


Serum 
Injected 


40c. c. 


30 


35 


30 














Fluid 
Removed 


80c.c. 


40 


40 


40 






55 




20 




Nature 
of Fluid 


Purulent 


Slightly 
Turbid 


Slightly 
Turbid 


Almost 
Clear 






Clear 




Clear 


Organisms 


Many 


Few 


None 


None 






None 




None 



Fig. 115. — Cerebrospinal Meningitis Treated by Serum. Infant, 7 months old, 
Babies' Hospital: 24 hours ill; intense prostration; respiration, 80; signs of pul- 
monary oedema; general relaxation; stupor; profuse hsemorrhagic eruption. First 
fluid, purulent; amount removed, amount of serum injected, and the changes in 
the fluid shown in the chart. Immediate improvement in symptoms after first in- 
jection. Subsequent symptoms typical. A rise in temperature on the 8th day 
and the increase in leucocytes on the 9th and 10th days suggested relapse; but 
as fluid was clear and no organisms could be found in smears or by culture no more 
serum was given; complete recovery. 



Day 18 


19 


?n 


21 22 23 


24 25 26 27 


28 29 


30 31 32 


33 34 35 36 37 38 




III 








TOIL 


3;__+i__j 


:::ii:iii :::£:.!: 


106° S 










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103 c j| 














= ^f-i-A- Hn=p ^Hfr ^^ = = F r ^ = = = ^ = 


102 c |3 
I0l c g 

100 c || 










jfefrjj 






99° |] 
B7° 


—X 


— 


— |=H|H 


|H|||h|= 




i.i.Br^i 


e t — ""'-1 '""" \SS- 



Fig. 116. — Cerebrospinal Meningitis. Late injection of the serum, prompt effect; 
complete recovery. Boy, 11 years, St. Vincent's Hospital, New York. Early symp- 
toms obscure, and on account of swelling and pain in joints diagnosis of rheu- 
matism made; cerebral symptoms not marked. First lumbar puncture made on 
3 1st day and meningococcus found. Serum injected on the 34th and 35th days. Rapid 
fall in the temperature followed by cessation of all symptoms and complete recovery. 



CEREBR0-SP1NAL MENINGITIS. 



715 



have almost invariably terminated fatally; with Berum over 50 per cent 
of the in have recovered. 

The results are much modified by the time of injection as shown by 
the following table : 

Mortality of serum-treated cases according to time of injection. 



Time of Injection. 


Flexner. 

(All sources, 
chiefly U.S.) 


Netter. 
(France.) 


Dopier. 
(France.) 


1st to 3d day 


14.9% 

22.0% 
36.4% 


7.14% 

11-1 % 
23.5 % 


8.20% 
14.4 % 
24.1 % 


4th to 7th day 

After the 7th day 



In Netter' s series Flexner' s serum was used; Dopter used the serum prepared 
at the Pasteur Institute. 



The effect on the 
course and duration of 
the disease is no less 
marked than that upon 
the mortality. The du- 
ration of acute symp- 
toms is very much short- 
ened, and in about one- 
fourth of the cases the 
disease terminated by 
crisis (Figs. 116, 117). 
This was more often 
seen in cases injected 
early, although it -was 
observed in some in- 
jected as late as the 
fourth week. The in- 
frequency of complica- 
tions and sequelae is also 
noteworthy. Not only 
do patients recover, but 
they recover quickly, and 
in most instances com- 
pletely. The absence of 
complications and se- 
quelae is, no doubt, to be 
explained partly by the 
effect of the serum in 
shortening the disease. 



Day 


1 


2 3 4 5 6 
























> 






" 3C 


106° 
















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4t 


105° 




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if 






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r t 






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104° 




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103° 




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IT 






_f 






T 






± 


102° 




£ 






t t 




t 


r t 






t 






-t 


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tL X -/£ 






4 A- 7t 






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100° 




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4 til 






\-t -\ 






-\j 






\J- t- 


99° 




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r t -n 






T 7\ > 






.J i-.i2p>_2^p--_- 


98° 




^7 rr^ 'n 




: t ■ jsz ■ 


























97° 







Fig. 117. — Cerebro-spinal Meningitis. Termina- 
tion by crisis; recovery after two injections. Boy of 
6 years, patient of Dr. C. H. Dunn. The first day, 
rather indefinite symptoms — headache, vague pains, 
slight fever. Second day, alarming symptoms rap- 
idly developed and patient became comatose; 30 
c.cm. of serum given and repeated the following day. 
The temperature rapidly fell and did not again go 
above 101° F. In twelve hours the coma was gone 
and the mind clear; by the fourth day the child was 
convalescent. No subsequent symptoms. 



716 DISEASES OF THE NERVOUS SYSTEM. 

Relapses occur in a small proportion of the cases. They are due to 
the fact thai the organisms have uoi been entirely destroyed by the 
serum. They are usually indicated by a rise in temperature, an increase 
in the leucocytosis, and an aggravation of the nervous symptoms. They 

are to be treated Like a primary attack, daily injections being repeated 
so bug as organisms and symptoms persist. 

Very little improvement is to be expected in patients who have 
I the febrile stage and who are suffering chiefly from the effects 
of distention of the ventricles due to a chronic basilar lesion. The most 
unpromising early cases are those of the fulminating type which have 
usually advanced so far before the serum is given that recovery is im- 
possible. Unpromising also are cases in which a very thick purulent 
tin id is present which can hardly be withdrawn through the needle. The 
amount which can be removed is usually very small. The diffusion of 
the serum in the canal is difficult. In such cases Eobb (Belfast), before 
injecting the serum, has used with success irrigation of the spinal canal 
with a warm sterile salt solution. In some cases, particularly in infants, 
where the withdrawal of fluid by lumbar puncture has been impossible 
owing to adhesions or other causes, fluid may be removed by puncturing 
the ventricles of the brain through the fontanel. The serum is then in- 
jected into the same cavity. The procedure is not very difficult, and, if 
carefully done, attended by little risk. I have used it in two cases. The 
effect of the serum seemed quite as marked as when it was introduced in 
the usual manner. 

In any case suspected to be cerebro-spinal meningitis lumbar punc- 
ture should be made as early as possible. If the fluid obtained is puru- 
lent or only slightly turbid, the serum should be injected at once. If 
the fluid is clear, the disease is probably not cerebro-spinal meningitis, 
and one may wait for a bacteriological report. Meningitis due to the 
pneumoeoccus, the bacillus of influenza, or pyogenic organisms, may also 
give a purulent fluid, but no harm would result from using the serum 
in such a case, although no benefit should be expected. 

Lumbar puncture per se has some slight therapeutic value. It re- 
3 pressure and by reducing the number of micro-organisms may have 
a slight effect upon the inflammatory process, especially when used early; 
but in most cases this is only temporary. An ice-cap should be applied 
to the head, and at times an ice-bag along the spine. The bowels should 
be kept freely open. Treatment otherwise is directed toward the symp- 
toms of the disease. Severe pain requires morphine or codeine some- 
times in quite large doses. For other nervous symptoms — delirium, 
sleeplessness, etc.— the bromides and chloral, sulfonal, or trional may be 
given, or warm sponge or tub baths. Stimulants are indicated by a 
weak, rapid, and irregular pulse. Caffeine and digitalis or strophanthus 
should he used, but not strychnine. 



ACUTE MENINCITIS DUE TO OTHER CAUSES. 717 

The nutrition of the patienl is important. Feeding is often difficult, 

and gavage may be advantageously employed. Bed-sores should be pre- 
vented by cleanliness, frequently changing the patient's position, etc. 
Retention of urine may require the use of the catheter. 

For the residual paralysis, massage, warm baths, and friction should 
be employed, but electricity only when all symptoms of central irritation 
have subsided. The prolonged use of iodide of potassium, especially in 
combination with mercury, seems to have some value. 



ACUTE MENINGITIS DUE TO OTHER CAUSES. 

Besides the main varieties of acute meningitis, viz., that due to the 
meningococcus and that due to the tubercle bacillus, there are other 
forms differing in etiology, but closely related clinically, and therefore 
they may be advantageously considered together. It is only since the 
general adoption of lumbar puncture as a means of diagnosis that these 
forms of meningitis have been clinically differentiated. Formerly they 
were grouped under the somewhat indefinite heading of " simple menin- 
gitis." Three of these varieties, those due to the pneumococcus, the in- 
fluenza bacillus, and pyogenic organisms, are sufficiently important to 
require separate description. Cases of meningitis due to the typhoid 
bacillus, the gonococcus, and the colon bacillus, have all been reported 
in children, but are so rare as only to deserve mention. 

Pneumococcus Meningitis. — This is the most important variety in- 
cluded in this group and the one most frequently met with in young 
children. In my hospital patients eleven per cent of the cases of acute 
meningitis were of this form. All had pulmonary symptoms of greater 
or less severity, and two-thirds of the patients had definite pneumonia 
with consolidation; several had also empyema. Less frequently, pneu- 
mococcus pericarditis and peritonitis have been present. Occasionally 
pneumococcus meningitis is seen when there are no definite pulmonary 
symptoms or signs and when it is apparently a primary inflammation. 
However, in most cases pneumococcus meningitis is one of the results 
of a generalised pneumococcus infection. In every one of seven cases of 
pneumococcus meningitis of my own in which cultures of the heart's 
blood were made at autopsy, this organism was present. This form 
of meningitis occurs in infants more frequently than in older children, 
and, in my experience, usually in very young infants; over half of the 
cases seen were in patients under six months old. While the disease 
usually develops at the height of an attack of pneumonia, it may pre- 
cede the pulmonary symptoms and it may develop during convalescence. 
I once saw it as late as the fourth week. 

Lesions. — In a general way the anatomical changes resemble those 
described in cerebro-spinal meningitis, with the exception that the 



;m DISEASES OF THE NERVOUS SYSTEM. 

marked changes in the brain substance which are usually dependenl upon 
the long course of thai disease are wanting. ' As a rule, also, the lesions 
are limited to the brain. If the cord is involved, it is only to a slight 

ee 

Acute meningitis due to the pneumococcus is characterised by a more 
abundanl exudation of fibrin and pus than is seen in any other variety 
of meningitis. The lesion may affect the entire brain, but it is espe- 
cially marked at the convexity and over the anterior lobes. Sometimes 
it is limited to these regions, the meninges of the base escaping. The 
exudate may be so abundant as almost to conceal the convolutions. (See 
Piatt* XIV.) There is usually less distention of the ventricles than in 
cerebro-spinal meningitis. 

In cases apparently primary, or when meningitis occurs very early in 
the course of a general pneumococcus infection, the symptoms are usually 
indistinguishable from ordinary cases of cerebro-spinal meningitis. It 
is generally not until lumbar puncture is made that the variety of menin- 
gitis is Buspected. When meningitis occurs as a secondary inflammation 
it is often latent, and not infrequently is found at autopsy when not 
suspected during life. Usually, however, the meningeal complication 
is indicated by the abrupt development, in the course of an attack of 
pneumonia, of vomiting or convulsions, followed by active delirium or 
stupor. Because the lesion is principally, sometimes only, at the con- 
vexity, many of the symptoms belonging to meningitis with basal lesions 
are absent. There is rarely cervical opisthotonus; the fontanel may not 
be bulging; pulse and respiration may not be disturbed; in fact, there 
are no cranial nerve symptoms and the symptoms due to spinal in- 
volvement — hyperesthesia, rigidity, Kernig's sign, etc., are usually 
wanting. 

The course of pneumococcus meningitis is generally short and acute, 
death taking place within three or four days from the first symptoms. 
I have twice seen a prolonged type of the disease lasting many weeks; 
one case ended fatally near the end of the third month ; the other patient 
recovered from the acute symptoms, but remained partially paralysed 
and mentally defective. 

The diagnosis of pneumococcus meningitis can positively be made 
only by Lumbar puncture. The cerebro-spinal fluid in gross appearance 
does not differ from that seen in cases due to the meningococcus. The 
cells present are chiefly polymorphonuclear. Pneumococci are very abun- 
dant and are easily found in smears and grown readily in cultures. The 
ace of pneumococcus meningitis is not always shown by lumbar 
puncture. I have met with one case in which repeated punctures gave 
uegative results, and yet the autopsy showed meningitis to be present, 
but only the convexity was affected. The organisms were readily found 
in the meningeal exudate. 



PLATE XIV. 




Acute Meningitis, complicating Pleuropneumonia. 

Child twenty months old ; on twenty-third day of a protracted attack of pneumonia, 
vomited six times, and the temperature, which had been nearly normal for four days, 
rose to 103° F. On the following day general convulsions, which were repeated fre- 
quently during the next few days ; temperature, 101° to 104° F. ; death in convulsions 
on twenty-eighth day. 

Autopsy. — Pleuro-pneumonia of left side ; lung resolving. Anterior portion of 
brain enveloped in lymph and pus, more marked at the convexity, but present also 
over the base. 



ACUTE MENINGITIS DUE TO OTHER CAUSES. 719 

Influenza Meningitis. — This form of meningitis is rare, but in many 
respects resembles the form just described. According to Wollstein, 1 
there had been recorded, up to 1911, 49 cases of pure, and 9 cases of 
mixed, influenza meningitis. Of these, 28 were in infants under one year 
old. Of the reported cases, 5 recovered, 2 of these being in infants. Of 
the 5 cases which have come under my own observation, one was in a boy 
of four years; the others were in infants. All ended fatally. In my 
experience, influenza meningitis has been secondary to other influenza 
infections, usually those of the naso-pharvnx or bronchi. The organism- 
were found by culture from the secretions of these parts during life. One 
patient, an infant of eight months, was admitted to the hospital with an 
acute abscess of the elbow. Two days later symptoms of meningitis 
developed, and death occurred in three days. The autopsy showed an 
extensive purulent meningitis. Pure cultures of the influenza bacillus 
were obtained from the pus of the elbow, the fluid drawn by lumbar 
puncture, the meningeal exudate, and the heart's blood. The lungs 
showed influenza bacilli and streptococci. 

The lesions of influenza meningitis, in the few cases in which autop- 
sies have been made, have differed in no essential particular from those 
described in the pneumococcus variety. In three of the cases coming 
under my observation in which examinations were made, the influenza 
bacillus was obtained from the heart's blood as well as from the cerebro- 
spinal fluid. 

Clinically, influenza meningitis runs a short, very acute course. 
There are no features by which it can be distinguished from the pneu- 
mococcus or meningococcus form, except the findings of lumbar punc- 
ture. In gross appearance the fluid does not differ from that seen in 
the other forms. There is usually marked turbidity; the cells are abun- 
dant and of the polymorphonuclear variety. The organisms are gen- 
erally not numerous in the smears, in marked contrast to the other 
forms of meningitis. They are readily grown upon blood agar, but not 
upon ordinary media. If, therefore, from a turbid cerebro-spinal fluid 
no growth occurs, influenza meningitis should be suspected. 

Meningitis Due to Pyogenic Organisms — Septic Meningitis. — Menin- 
geal inflammations set up by the streptococcus and staphylococcus are 
not very common in young children. They are almost always secondary. 
In the newly born this form of meningitis is seen in general pyaemia, 
usually from umbilical infection; it also follows infection of a spina 
bifida. In older children it follows injuries to the head, erysipelas of 
the scalp, operations upon the brain, and otitis media with mastoiditis 
or sinus thrombosis. Such a complication of otitis in infancy is, how- 
ever, extremely rare. The lesions consist in a widespread general in- 

1 American Journal of Diseases of Children, January, 1911. 



720 DISEASES OF THE NERVOUS SYSTEM. 

ftammation of the pia with an abundant exudate of pus, but with less 
fibrin than in the two varieties previously described. 

The symptoms of septic meningitis are not distinctive. The course 
is usually a rapidly progressing one, and the termination almost invari- 
ably in death. The fluid drawn by lumbar puncture in most cases is 
markedly turbid, and shows great numbers of pus cells. The organisms 
are present in large numbers and are readily recognised both in smears 
and by cultures upon ordinary media. 

Diagnosis. — The differential diagnosis of the different forms of menin- 
gitifl from each other, and from other diseases with cerebral symptoms, 
is made with certainty only by means of lumbar puncture, which should 
be done in all cases of doubt. The appearance of the cerebro-spinal fluid 
ntially the same whether the inflammation is dne to the meningo- 
eoccus, the pneumococcus, the influenza bacillus, or to the staphylococcus 
or streptococcus. The symptoms of meningitis in general, fully de- 
scribed in the chapter on Cerebro-Spinal Meningitis, are present in most 
(if the cases. 

Prognosis and Treatment. — The prognosis in all varieties of acute 
meningitis, except that due to the meningococcus, is very bad; almost 
every case of meningitis due to other causes is fatal. From what has 
been said, it would appear that treatment is as yet most unsatisfactory, 
and only symptomatic. Wollstein's researches at the Eockefeller In- 
stitute, however, indicate that influenza meningitis may yet be controlled 
by serum treatment. A goat serum has been produced which regularly 
controls the experimental disease in monkeys, although its use has not 
yet been extended to man. 

TUBERCULOUS MENINGITIS. 

(Acute Hydrocephalus; Basilar Meningitis.) 

Tuberculous meningitis is a tuberculous inflammation of the pia 
mater of the brain, sometimes involving also that of the cord. It is by 
far the most frequent form of acute meningitis seen in young children. 
In my hospital experience, apart from epidemics of cerebro-spinal menin- 
gitis, seventy per cent of the cases of acute meningitis have been tuber- 
culous. It is more uniformly fatal than any other disease of early life. 
[t is doubtful if it ever occurs as the only tuberculous lesion of the body. 
In infancy it is usually associated with general or pulmonary tubercu- 
losis ; in older children with tuberculosis of the bones, joints, or lymph 
nodes. Of my own cases, forty per cent' of all deaths from tuberculosis 
in children have been due to meningitis. 

Lesions. — The lesion consists in the production of miliary tubercles, 
with which are frequently found tuberculous nodules of variable size, and 
in almost every case there are also the products of ordinary inflammation 



TUBERCULOUS MENINGITIS. 721 

of the pia mater — fibrin and pus — together with an accumulation of 
fluid in the lateral ventricles of fche brain. Frequently there are tubercles 
in the pia mater of the Upper portion of the cord. When few in number 
the tubercles are usually only at the base. When numerous they are seen 

scattered oyer the convexity. Tubercles are sometimes found in the 
choroid coat of the eye. The amount of fibrin and pus in the exudate 
is usually small, and is much less than is seen in other forms of acute 
meningitis. The inflammatory products arc most abundant at the base. 
In addition to the patches of greenish-yellow fibrin, there arc adhesions 
between the lobes of the brain and thickening of the pia. In cases which 
have lasted for several weeks, this thickening may be marked, owing 
to cell infiltration and the production of new connective tissue. The 
pia is studded with miliary tubercles, sometimes with small yellow 
tuberculous nodules; frequently there is arteritis, which is sometimes 
obliterating. 

In the most acute cases the brain substance immediately beneath the 
pia is intensely congested, slightly softened, and shows under the micro- 
scope a superficial encephalitis. The lateral ventricles are usually dis- 
tended with clear serum, sometimes with serum containing flocculi of 
fibrin or pus : the amount present varies from one to four ounces in each 
ventricle, being always greater in the subacute cases. The walls of the 
ventricles may be softened. The distention of the ventricles leads to 
flattening of the convolutions from pressure against the skull, to bulging 
of the fontanel, and sometimes to separation of the sutures. 

Tuberculous nodules varying in size from a small pea to a walnut are 
frequently seen associated with meningitis in older children, but not 
often in infants. These nodules may be connected with the meninges, 
or they may be situated within the brain substance, usually in the cere- 
bellum. The larger ones are classed as brain tumours. Inflammatory 
products are rarely found in the spinal canal. 

Although it is not infrequent to see meningitis without symptoms of 
tuberculosis elsewhere, I have never failed at autopsy to find other tuber- 
culous lesions in the body. In my own experience the following are 
those most often met with, given in the order of frequency: (1) In in- 
fants, associated with general or pulmonary tuberculosis; (2) in chil- 
dren from three to twelve years of age, with tuberculosis of the vertebrae, 
hip, knee, or ankle; (3) at any age, with tuberculosis involving only 
the tracheal, bronchial, or mesenteric lymph nodes; (4) much less 
frequently with the pulmonary tuberculosis of older children. 

Etiology. — Tuberculous meningitis is produced only by the transpor- 
tation of the tubercle bacilli to the brain. They may find their way by 
the blood-vessels or lymphatics. 

The following table shows the age at which the disease was observed 
in 410 cases of which I have notes : 
47 



DISEASES OF THE NERVOUS SYSTEM. 

Under one year 162 

One to two years 149 

Two to five years 76 

Five to nine years 17 

Nine to sixteen years 6 



Total 



410 





1 Jan 


M 


Uct. 


\,.r. 


Uaj 


June 


July 


Aug. 


Scpl 


Oct 


N„v. 


Dm. 




1400 
1200 
1000 
800 
600 
400 
200 


36 


























1400 
1200 
1000 
800 
600 
400 
200 


33 








A 


















30 








'\ 


















27 










\ 
















24 










\ 
















21 












\ 














18 


^ 




r 


-A 




\ 














15 


\ 


N/ 


/ 




v x 


\ 


\ 












12 




V 






\ 




V 












9 












\ 








s>> 








\ 


G 














v^ 




^' 








3 






















































In this series three cases were in children three months old or 
younger. Tuberculous meningitis occurs much more often in the winter 

and spring months than 
at other seasons (Fig. 
118). The most plausi- 
ble explanation of this 
seems to be that these 
patients, infected some 
time previously, carry a 
latent focus of tubercu- 
losis somewhere in the 
respiratory tract, usually 
the bronchial glands. 
Under the influence of 
acute respiratory infec- 
tions of the cold season, 
the latent tuberculous 
disease becomes active, 
and a rapidly spreading 
tuberculous process re- 
sults. In infants and 
young children it rarely 
happens that pulmonary 
lesions are absent; but these patients are especially predisposed to early 
meningeal infection, and this often occurs before symptoms of tubercu- 
losis elsewhere have manifested themselves. At the time of invasion, 
therefore, most of these children are apparently in the best of health. 
In older children there may have been previous evidence of tuberculosis 
in lungs, hones, or lymph nodes. The modes of acquiring tuberculosis 
are discussed in the general chapter on that disease. It is sufficient to 
say here that it is usually from some member of the family or household. 
This may be not only a person who is in the active stage of pulmonary 
tuberculosis, but one who is supposed to be cured or one in whom the 
*e has not yet been suspected. Exposure may antedate symptoms 
era) weeks or months. Striking evidence in favor of the human 
origin of tuberculous meningitis is obtained from a study of the type of 
tubercle bacillus present in cases of meningitis. In thirty-two cases in 
this was worked out by Dr. W. H. Park in the Research 



Fig. 118. — Seasonal Occurrence of Tuberculous 
Meningitis. The upper curve ( — ) represents the 
seasonal occurrence of 218 cases of tuberculous 

meningitis. The lower curve ( ) represents the 

deaths from pneumonia in New York City for one 
year. 



TUBERCULOUS MENINGITIS. 723 

Laboratory of the New York Health Department. In thirty the bacillus 
was of the human type; in one it was of the bovine type, and in one 
both types were present. 

Symptoms. — In about two-thirds of the eases the onsel is gradual; 
but in a considerable number of those classed as abrupt, careful inquiry 
will elicit a history of previous indisposition. The most frequent early 
nervous symptoms are: disinclination to play, drowsiness, or sometimes 
constant fretfulness or irritability. Often there is a complete change in 
disposition. In a ease under my observation this was most striking ; 
a little girl previously devoted to her mother, could not endure her 
presence in the room. Sleep is restless and disturbed; there may be 
grinding of the teeth. Older children often complain of headache. At 
all ages, but particularly in infancy, early digestive symptoms are prom- 
inent. There are seen frequent attacks of vomiting without apparent 
cause; the bowels are generally constipated and the appetite is almost 
entirely lost. Usually there is also a slight but continuous elevation of 
temperature. Indefinite symptoms may last for four or five days, or 
they may be spread over two or three weeks without perhaps being suf- 
ficiently severe to attract much notice. Finally, unmistakable evidence 
of brain disease develops. The early disturbances are often ascribed to 
dentition, or to indigestion. 

In most cases the first pronounced cerebral symptom is persistent and 
increasing drowsiness; exceptionally it is an attack of general convul- 
sions, followed in a few hours by stupor. Often a period of irritative 
symptoms is present, lasting several days. There is headache, usually 
located in the frontal region, and occasionally photophobia; sometimes 
pain is indicated by the child's suddenly screaming out at night, which 
may be repeated many times without waking; sometimes during the 
greater part of the time for two or three days these frequent screaming 
attacks may be repeated. The skin is somewhat hyperaesthetic ; the re- 
flexes are apt to be exaggerated; the muscles of the neck may be rigid 
and the head is drawn back, or there may be rigidity of the extremities. 
The pupils are normal or contracted; there may be nystagmus. The 
child is fretful, wishes to be left alone, and cries if disturbed. In some 
cases these symptoms are so marked as strongly to suggest cerebro-spinal 
meningitis. They may alternate with periods of marked apathy and 
dulness. During this stage there is occasional vomiting, and the bowels 
are obstinately constipated. The pulse is usually somewhat accelerated, 
but may be slow and occasionally it is irregular. The respiration is of 
normal frequency, but a careful observation during sleep or perfect quiet 
will often show a slight irregularity which is very significant. The 
temperature is usually elevated, ranging from 99° to 100.5° F. When 
a high temperature is seen, it is usually due to tuberculosis elsewhere 
than in the brain. 



J24 DISEASES OF THE NERVOUS SYSTEM. 

A- the disease advances, the irritative symptoms subside, and the stu- 
por becomes deeper and more continuous, [f undisturbed, the child may 
Bleep a great pari o( the time, but ran be roused, and then appears 
quite rational. Finally the stupor becomes so profound that the child can 
not be roused at all. Active delirium is rare. The pupils respond slowly 
to light or not at all; they may be unequal; occasionally there is seen 
strabismus, ptosis, or paralysis of the face. More often there is hemi- 
plegia, or paralysis of one arm or leg. Such paralyses are often transient, 
disappearing alter a day or two. Automatic movements of the extremi- 
ties, particularly of the arms, are frequent. Muscular twitchings may 
be noticed. Opisthotonus is marked and well-nigh constant. In infants 
the fontanel is tense and bulging. In older children especially the ab- 
domen is retracted, giving the typical "boat-belly." On drawing the 
finger-nail along the skin of the abdomen, there appears a distinct red 
streak, which remains for several minutes. This is the tdche cerebral e, 
ami it is almost always present. Other vaso-motor disturbances may be 
seen. The reflexes are variable; in the early part of the disease they are 
usually increased, later they are diminished or abolished. The pulse now 
becomes slow and irregular, often intermittent. The respiration is almost 
always irregular; a very characteristic type consists in the movements 
becoming deeper and deeper until there is a sigh; after a complete 
arrest of respiration for several seconds the phenomenon is repeated. 

The accompanying tracing il- 
lustrates the type (Fig. 119). 
An examination with the oph- 
Fig. 119.— Tracing of Respiration in Tuber- thalmoscope usually shows the 
culous Meningitis. % . . _ " / _ . 

presence of choked discs. 

The progress of the disease is subject to great variations, especially 
in children over two years old. The advance of symptoms is slower and 
i> interrupted by periods of remission which may continue two or three 
days. After being in quite deep stupor, a child may recover conscious- 
and even sit up and play with toys, leading to the view that an 
error in diagnosis has been made. But this respite is only temporary; 
soon the child passes again into coma. 

From this time the duration of the disease is from three to ten days. 
The child can not be roused at all. The pupils are widely dilated, and 
do not respond to light. There is general muscular relaxation. There 
may be retention of the urine. Deglutition is difficult, often impossible. 
The respiration is more rapid, but still irregular. The pulse becomes 
rapid and feeble, often 160 to 180 a minute. Toward the end the 
temperature rises rapidly to 104° F., sometimes to 106° or 107° F. 
(Fig. L20). Death usually takes place from exhaustion in deep coma, 
or convulsions develop and continue from twelve to twenty-four hours 
until death. Sometimes a patient will live for days in a condition of 



TUBERCULOUS MENINGITIS. 



725 



prostration so extreme that death is hourly expected. A rapidly rising 
temperature or the occurrence of late convulsions usually indicates ap- 
proaching death. Of fifty-seven cases, fifty died in coma, seven in con- 



DAY 




1 


2 


3 


4 


5 


G 


7 


8 


9 


10 


11 


12 


13 


14 


IB 


16 


17 


DATE 


OCT. 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


22 


23 


24 


26 


26 


in 

I 

z 
u 

K 

I 
< 

u. 

HI 
a 

H 

< 

E 
III 

0. 

E 
1- 


100° 
105° 

104° 

103° 

1U2° 
101° 
100° 

uy° 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 
/ 


































/ 
































^t 


J 






























/ 


V 






/i 


1 


N 




















r 


A 






A 


/ 


\ 


\n 


Ia 


A/ 


A 


AA 


A 




A 


A 


J 








/ 




Vu 




V 


V 


v\ 


/v 


V 


"V 


J 


V 
























V 






V 

















































Fig. 120. — Fairly Typical Temperature Curve in Tuberculous Meningitis. 
Boy, twenty months old; death on seventeenth day. 

vulsions. The entire duration of the disease from the beginning of 
definite nervous symptoms is rarely over three weeks, and in infants it 
is usually shorter than this. 

Diagnosis. — Tuberculous meningitis is often overlooked because the 
patients do not give outward evidences of tuberculosis. Its great fre- 
quency should always lead one to suspect it when protracted nervous 
symptoms are present in infants. There are no diagnostic symptoms in 
the early stage. The indefinite symptoms that belong to this stage of 
the disease are frequent in young children suffering from chronic indi- 
gestion associated with constipation. Cases of cyclic vomiting may 
present many of the symptoms of meningitis. 

The most diagnostic symptoms of tuberculous meningitis enumerated 
in the order of their frequency are as follows: persistent drowsiness, 
obstinate constipation, vomiting without apparent cause, irregular respi- 
ration, irregular pulse, convulsions, opisthotonus, and fever which is 
usually slight. A positive diagnosis is made only by lumbar puncture; 
by this means this form is distinguished from other forms of acute 
meningitis. 

The fluid drawn by lumbar puncture is usually perfectly clear, but 
sometimes after standing there is a slight deposit present. Exceptionally 
the fluid may be turbid. The cells are usually few in number, and of 
the mononuclear variety. The presence or absence of sugar has been 
in my experience of no diagnostic importance. 

Tubercle bacilli are, I believe, invariably present in the fluid, and 
by careful examination can be found microscopically in nearly every 
case. They were found in 135 of 137 consecutive cases of tuberculous 



726 DISEASES OF THE NERVOUS SYSTEM. 

meningitis mi the Babies' Hospital. 1 They are more numerous late in 
tin* disease. 

The technique is important. Fluid should be drawn into several 
tubes and the last one containing L5 or 20 ccm. set aside for examina- 
tion, as the bacilli are much more Likely to be found in this than in the 
first fluid. The tube should not be shaken, but should be allowed to 
Btand for twelve hours, preferably in an incubator. A central coagulum 
or film generally tonus in the fluid, and in this the bacilli are usually 
entangled. This should be spread out entire and carefully examined. 
In other rases the bacilli may be found after eentrif uging ; in still others 
l.\ scraping the sides of the tube with a platinum loop or by examining 
superimposed drops which have been allowed to dry upon a slide. In 
most of the rases the number of bacilli present is not large and the aver- 
age length of search required has been about an hour, but in a few in- 
stances the number is so large that they are present in practically every 
field. 

Noguchi's globulin test 2 is useful in distinguishing inflammatory 
from normal cerebro-spinal fluids. It is, however, of no value in dis- 
tinguishing between the different forms of meningitis. A positive re- 
action is obtained with great uniformity in every variety of acute men- 
ingitis. This test is of special assistance in the tuberculous cases, for in 
them the gross appearance of the fluid does not usually differ from the 
normal ; moreover, it gives early information. 

Bacilli have been found in the sputum, in my experience, in nearly 
one-half the cases in infants and young children, although in most of 
them there was either no evidence of pulmonary disease, or only cough 
and a few scattered rales in the chest. 

The v. Pirquet cutaneous test gives reliable information except 
in moribund cases, in those excessively prostrated, or with very poor 
circulation. A positive reaction was obtained in 51 of 65 consecutive 
tested, the negative results being usually for the reasons men- 
tioned. This tesl is of much assistance in early diagnosis. If then a 

Bemenway, American Journal of Diseases of Children, January, 1911. 
* The test is as follows: 
To O.o ccm. of a 10-per-cent solution of butyric acid in 0.9-per-cent salt solution 
add 0.1-0.2 ccm. of suspected fluid and boil. 

Then add 0.1 ccm. normal sodium hydrate solution and boil again. 
Xo change in the solution or only a faint cloudiness is to be considered a negative 
reaction. 

A flaky precipitate is a positive reaction. 

Note.- -The test should be controlled by boiling the two solutions without the 
suspected fluid. The reagents should be freshly made; they may change after two 
or three weeks. The accidental addition to the fluid of even a few drops of blood 
spoils the test, for this is sufficient to give the globulin reaction although no menin- 
giti- is present. 



CHRONIC BASILAR MENINGITIS IN INFANTS. 727 

child with symptoms distinctly meningeal gives a positive reaction to 
the tuberculin test the probabilities of tuberculous meningitis are greatly 
strengthened, even though at the time bacilli may not have been found 
in the cerebro-spinal fluid. 

The cerebral symptoms of intestinal and many other acute diseases 
sometimes closely resemble those of tuberculous meningitis. From all 
such the diagnosis is made by lumbar puncture. In any case of men- 
ingitis in a young child the chances are greatly in favour of the tuber- 
culous form, since it is much more frequent. The diagnosis of tuber- 
culous meningitis from the cerebral form of acute poliomyelitis is at 
times difficult. It is discussed under the latter disease. 

Prognosis.— Although there have been recorded a few instances of 
recovery after the tubercle bacilli have been found in the fluid obtained 
by lumbar puncture, such an outcome is not to be expected. I have 
never seen such a case recover. The reported recoveries in which the 
diagnosis has rested upon clinical symptoms only can not be accepted. 

Treatment. — From what has been said regarding prognosis, it follows 
that if the diagnosis is correct the case is practically hopeless, no matter 
what treatment is employed; but as a positive diagnosis is not always 
possible, all cases should be treated like other forms of acute meningitis. 



CHRONIC BASILAR MENINGITIS IN INFANTS. 

It was first pointed out in 1898 by Still that this disease is usually 
due to the diplococcus intracellularis ; in other words, that it is a chronic 
form of cerebro-spinal meningitis. Chronic basilar meningitis is most 
frequently seen after epidemics of cerebro-spinal meningitis, but it is 
occasionally met with at other times as a sequel of a sporadic case. It 
occurs after an acute attack, when the basilar lesion persists and be- 
comes chronic. As acute cerebro-spinal meningitis in infants is usually 
fatal if the attack is severe, it follows that the chronic form is seen 
only after the mild attacks. It is chiefly for this reason that the early 
symptoms often are not recognised as those of cerebro-spinal meningitis. 
The patient frequently does not come under observation until all acute 
symptoms have passed away, the persistent opisthotonus being the chief 
feature of the case. 

There is also seen in children, though very rarely, a chronic basilar 
meningitis of syphilitic origin. At least two such ca?es have come under 
my observation in the Babies' Hospital. One was cured by anti-syphilitic 
treatment, and in the other the diagnosis was confirmed by autopsy. 

Lesions. — This process is usually limited to the base of the brain. 
The pia mater is thickened about the interpeduncular space, also over the 
medulla, pons, and cerebellum. These different parts may be adherent to 
each other, or to the inner surface of the dura. The cranial nerves may 



728 DISEASES OF THE NERVOUS SYSTEM. 

be compressed. The openings in the fourth ventricle are usually ob- 
literated, and there results a distention of the lateral ventricles with 
clear serum, sometimes in sufficient amount to be regarded as hydro- 
cephalus. Rarely, pus may be found in the ventricles. 

Symptoms. The onset is usually gradual, although in most cases 
there ran be obtained a fairly distinct history of an early active period. 
The most prominent symptoms are cervical opisthotonus, moderate hydro- 
cephalus, and usually general muscular rigidity. The opisthotonus is 
often extreme ( Fig. 121) and is greater than is seen in any other disease. 
If placed upon its hack the body of the child often touches the table only 
at the occiput and the sac-rum (Fig. 122). The head is usually some- 
what enlarged, hut never to the degree seen in primary hydrocephalus; 
the fontanel bulges, and the sutures are separated. These symptoms 
are due to an accumulation of fluid in the lateral ventricles; they are 
never so marked as in primary hydrocephalus. The rigidity of the ex- 
tremities is very great and in most cases constant; the legs and feet 



Fk;. 121.— Chronic Basilar Meningitis — Extreme Deformity. Ill for five months; 
followed cerebrospinal meningitis; posture shown in the picture maintained for the 
last six weeks; death at ten months. Autopsy showed typical lesions. 

are usually extended, while the forearms are flexed and the hands 
clenched. All the reflexes are greatly exaggerated. There is rarely 
coma, hut mental dulnesa alternating with periods of great irritability 
in which genera] convulsions may occur. Vision may be impaired or 
ranting entirely. The fact that in most cases optic neuritis is absent 
some value in differentiating this disease from tumour. Xystagmus 
is often j> resent and attacks of vomiting occur without evident cause. 
There is no fever except for a few days at a time during acute exacerba- 
tions. The usual duration of the disease is from two to five months; 



THROMBOSIS OF THE SINUSES OF THE DURA MATER. 729 

death may occur from convulsions, or from some intercurrent disease, 
such as pneumonia, but most frequently from marasmus. The prognosis 
is very bad except when the cause is syphilis, when recovery may take 
place. 

Diagnosis. — The disease is to be distinguished from tuberculous men- 
ingitis, and from the opisthotonus of reflex origin which is occasionally 
seen in infants suffering from marasmus. It differs from tuberculous 







Fig. 122. — Chronic Basilar Meningitis. 
A patient in the Babies' Hospital (diagnosis confirmed by autopsy). 

meningitis in its more protracted course, in the absence of fever and 
paralysis, and also in the greater prominence of the opisthotonus and 
hydrocephalus. 

Treatment. — If there is any reason to suspect syphilis, salvarsan and 
the iodide of potassium and mercury should be administered. Lumbar 
puncture is useful for diagnosis only. The establishment of auto-drainage 
of the ventricles, as practised in primary Jrydrocephalus, has recently been 
advocated for this condition, and tried with some measure of success. 



THROMBOSIS OF THE SINUSES OF THE DURA MATER. 

This is not very frequent. It may depend upon certain general con- 
ditions, when it is usually classed as cachectic or marantic thrombosis; 
it may be associated with local pathological processes, when it is known 
as inflammatory or septic thrombosis. 

Cachectic Thrombosis. — This is seen in infants and young children, 
but is very rare after the age of five years. It occurs in the course of 
various diseases, the most frequent being pneumonia, pertussis, diph- 
theria, nephritis, tuberculosis, and the acute intestinal diseases. In 



730 DISEASES OF THE NERVOUS SYSTEM. 

connection with the last-mentioned group, altogether too much has been 
made of it. as it is really pare, and in only a very few eases does it explain 
erebraJ symptoms present. The actual cause of the thrombosis is 
the altered rendition of the blood and the feeble circulation, as the walls 
of the sinuses are normal. 

The most frequent seat of cachectic thrombosis is the superior longi- 
tudinal sinus. At autopsy one must be careful not to confound the soft, 
partly decolourised, non-adherent thrombi of post-mortem origin, with 
those of ante-mortem formation. The latter are firm, and when of long 
standing may he very hard and even show a laminated structure. They 
usually fill the sinus completely, and are adherent. The thrombus ex- 
tends from the sinuses to the veins emptying into it, which stand out 
like dark worms upon the surface of the brain. The brain itself may be 
deeply congested, or it may be covered with a diffuse haemorrhage, but 
more frequently the brain and the membranes are simply cedematous. 

The symptoms of cachectic thrombosis are few and uncertain, and in 
a large number of cases the disease is latent. Very rarely is a positive 
diagnosis possible during life. When the thrombosis occurs just before 
death, its symptoms are so mingled with those of the original disease 
that they can not be separated. In some cases there may be localised 
or general convulsions, or paralysis, loss of consciousness, and strabismus. 

The prognosis is bad, cases generally proving fatal in the course of a 
few days. The diagnosis is so uncertain and obscure that the treatment 
must he symptomatic, and directed toward the general rather than the 
local condition. 

Inflammatory Thrombosis — Septic Thrombosis — Sinus-Phlebitis. — This 
condition is most frequently seen in children in connection with acute 
meningitis. It may exist either with the simple or the tuberculous 
variety. It also follows otitis — especially old and neglected cases — usu- 
ally with necrosis of the petrous bone, but sometimes without it. It is 
much less frequently associated with disease of the ear in children than 
in adults. It may arise from traumatism, necrosis of the cranial bones, 
or from septic processes involving any of the cavities or any of the 
structures adjacent to the brain, such as the scalp, orbit, nasal fossa, 
mouth, or pharynx. Infection from the mouth or pharynx is most fre- 
quent in children in connection with scarlet fever or diphtheria; while 
usually secondary to otitis it may occur without it, the infection being 
carried by the blood-vessels. Infection from the nose may have its 
origin in ulceration from syphilis or tuberculosis. In the orbit, the 
source may be malignant disease. 

The seal of the thrombosis will depend upon the original disease. If 
this affects the cranial bones or the scalp, it will be the longitudinal 
sinus; if the ear, the lateral sinus; if the base of the skull, the orbit, 
the mouth, the jaw, or the nose is affected, it will be the cavernous sinus. 



CEREBRAL ABSCESS. 731 

When thrombosis occurs with meningitis the lesions are much the same 
as in the cachectic form, with the exception that there are sometimes 
slight changes in the walls of the sinuses. If the patient has suffered 
from a local septic process, there may be puriform softening of the 
clot, and general pyaemia, with the development of secondary absces 
in the brain, in the lungs, and in other organs. With such cases there 
may be associated a general or localised meningitis. 

Symptoms. — The symptoms of septic thrombosis are more decided 
than those of the cachectic form. When occurring in the course of men- 
ingitis, it usually adds no new symptoms to those of the original dis- 
ease. In the pyaemic form the symptoms are more characteristic, par- 
ticularly when associated with otitis. There are recurring chills with 
very high and widely fluctuating temperature. There is headache, and 
often localised tenderness of the scalp; the other symptoms which are 
present are usually the same as those of meningitis. If metastasis oc- 
curs, there may be evidences of abscesses in the brain or in other organs, 
and sometimes there are signs of suppuration in the jugular vein. A 
polymorphonuclear leucocytosis is usually present, and blood cultures 
in most cases show the presence of pyogenic organisms. 

The local symptoms of the thrombosis differ somewhat according to 
the sinus affected: if its seat is the superior longitudinal sinus, there 
may be cyanosis of the face, dilatation of the temporal and frontal veins, 
and sometimes epistaxis ; if the lateral sinus is involved, the process may 
extend to the jugular vein, which may be felt in the neck as a hard 
cord, and there may be dilatation of the veins of the mastoid region, and 
even localised oedema ; when the cavernous sinus is affected, there may be 
protrusion of the eyeball of the affected side, oedema of the lid, and with 
the ophthalmoscope the retinal veins appear enlarged and tortuous, some- 
times being the seat of thrombosis. The process may affect either one 
or both sides. The course of septic thrombosis is rather irregular, vary- 
ing from a few days to three weeks. In fatal cases death takes place 
from meningitis, cerebral abscess, or pyaemia. The prognosis is very 
grave, unless the disease is so situated that it is accessible to surgical 
operation. 

Treatment. — The only successful treatment is surgical. Operation 
is easiest in thrombosis, of the lateral sinus, being much more difficult 
if involving the superior longitudinal sinus. So many cases are now on 
record of successful operation upon septic thrombosis of the lateral sinus, 
that it should always be urged when the diagnosis is clear. 

CEREBRAL ABSCESS. 

Cerebral abscess is quite rare in children, decidedly more so than is 
cerebral tumour. In Gowers' collection of 223 cases, only twenty-four 



DISEASES OF THE NERVOUS SYSTEM. 

won' under ten years of age. In infants, abscess is one of the least fre- 
quent diseases of the brain, and up to five years it is exceedingly rare. 

Etiology. — By tar the most frequent cause in children is otitis. This 
is the origin of the groat majority of the cases. Abscess rarely compli- 
catea acute otitis, but is soon with the chronic form. Exactly how otitis 
causes cerebral abscess it is not always easy to determine. Usually 
there is caries o\' the petrous bono, but there may be none. The infection 
may extend through the small veins traversing this bone, or along the 
lateral sinuses to the cerebellum. Abscess is often attributed to the re- 
tention of pus in the ear, but it may occur when the discharge is free. 

Traumatism is the second important etiological factor. Abscess may 
sociated with fracture of the skull, or follow simple concussion. The 
abscess is generally in the neighbourhood of the injury, but occasionally 
is produced by contre coup. In one instance, reported by Wagner, thrush 
was believed to be the cause of cerebral abscess, the same fungus that 
existed in the mouth being found in the brain, which in this case was 
studded with small abscesses. Abscess may be the result of infectious 
emboli, associated with general pyamiia, though this is rare in early life; 
and finally it may occur without any assignable cause. 

Lesions. — The most frequent seat of the abscess is, first, the temporo- 
sphenoidal lobe; secondly, the cerebellum; thirdly, the frontal lobes. 
Other locations are very rare. Abscesses are usually single. In size they 
vary from that of a small cherry to an orange. One case was observed 
by Meyer, in which an abscess occupied one entire hemisphere. The 
contents are usually thick greenisb-yellow pus, which may be very foetid. 
When ab-cesses have lasted for some time they are usually surrounded 
by a dense pyogenic membrane, and may become encysted. The patholog- 
ical process may be slow, and often is apparently stationary for a long 
period. Abscesses may rupture into the ventricles, less frequently upon 
the surface of the brain, causing meningitis, or the pus may even escape 
externally through the auditory meatus. 

Symptoms. — These are general and local. The general symptoms are 
much the more important for diagnosis, and often are the only ones 
■it. The local symptoms are those of a tumour. The clinical history 
of a case of abscess of the brain may be divided into three stages: First, 
the period of onset, or early acute inflammatory symptoms, fever, etc., 
which attend the formation of pus. Secondly, the latent period, or period 
of remission, in which very few symptoms are present. In many acute 
this stage is wanting altogether; in the chronic cases it may last 
for months, or even years. Thirdly, the final period, with recurrence 
of active cerebral symptoms, followed by death in a few days. 

The onset may be accompanied by symptoms so slight as almost to 
escape notice. In most cases, however, headache and fever are present. 
The headache ig usually severe, and often localised upon the affected 



CEREBB \1, ABSCESS. 733 

side; in cerebellar abscess it may be occipital. The lever is moderate in 
intensity, and continuous. In addition there may be vertigo, vomiting, 
general convulsions, and cessation of the aural discharge, if one has 
been present. The duration of this stage is variable; it may be only a 
few days, or several weeks. It is shorter in traumatic cases, and in 
those which are due to pyaemia. 

The latent stage, or period of remission of symptoms may be quite 
short — only a few days' duration — and it is often absent. During this 
period the temperature may fall quite to the normal, and the headache 
disappear, or be only occasional and slight. However, if any focal symp- 
toms have been present they remain unchanged. 

The symptoms of the terminal stage are due to a rapid extension of 
the inflammatory process, with oedema and softening about the abscess, 
sometimes to rupture into the ventricle, and sometimes to meningitis. 
The fever now returns, and may be high. There is headache, often 
very intense and continuous; there may be delirium and convulsions, and 
the gradual development of coma. In addition there may be vomiting, 
paralysis, opisthotonus, retracted abdomen, and the other symptoms of 
meningitis. Occasionally all the earlier symptoms may be latent, and 
the terminal symptoms may be the only ones present. In infants, the 
fontanel is usually large and bulging; convulsions are rather more fre- 
quent than in older children. 

The local symptoms of abscess are rather indefinite, owing to its 
usual situation. Abscesses of considerable size may exist in the temporo- 
sphenoidal lobe, in the central part of the frontal lobe, or in the cere- 
bellum, without any definite local symptoms. If the abscess is near 
the motor area, there are the usual symptoms of disease in this location : 
spasm, or paralysis of the face, arm, or leg. A cortical or sub-cortical 
abscess is likely to cause convulsions. Cerebellar abscess may give rise 
to occipital headache, frequent vomiting, and when the abscess is large 
enough to press upon the middle lobe, there may be inco-ordination of 
the muscles of the extremities. Optic neuritis may be present, but other 
symptoms relating to the cranial nerves are rare. Localised tenderness 
over the scalp, when persistent, is a symptom of importance, and may 
serve to locate the abscess, if it is superficial. 

Diagnosis. — Of the general symptoms, the most important for diag- 
nosis are fever, headache, delirium, and terminal coma. These become 
particularly significant when following otitis or traumatism. The dif- 
ferential diagnosis of abscess is to be made principally from tumour 
and meningitis, and from these conditions more by the history and gen- 
eral course of the disease than by any special symptoms. The diagnosis 
of abscess from tumour is considered in connection with the latter dis- 
ease. It is more difficult to distinguish between meningitis and abscess, 
since the two processes are often associated. With meningitis convul- 



DISEASES OF THE NERVOUS SYSTEM. 

Biona are more common, bul they are rarely localised; rigidity and the 
inflammatory Bymptoms are more intense; the course is usually more 
rapid and more regular, being rarely interrupted, as is the course of 
Leucocytosis is more constant and usually more marked in 
meningitis. Lumbar puncture gives negative results in uncomplicated 
38 while it gives positive definite information in meningitis. From 
the cerebral symptoms occurring with otitis it is extremely difficult to 
distinguish abscess, for optic neuritis may be present in the former as 
well as in the latter condition. The more intense and prolonged the 
cerebral symptoms and the more marked the neuritis, the greater are 
the probabilities of abscess. 

Prognosis. — The prognosis in cerebral abscess is always grave, unless 
accessible to surgical operation. The progress may be slow, or rapid, but 
it i> inevitably from bad to worse, and sooner or later the disease, if not 
interfered with, proves fatal. 

Treatment. — The medical treatment of abscess in its active stage is 
that of any acute intracranial inflammation — ice to the head, absolute 
quiet, tree catharsis, and full doses of the bromides or morphine, if pain 
is intense. The absolutely hopeless condition of these cases when left 
to themselves, and the recent brilliant results from surgical operations, 
should lead the physician to urge operation in every case. 

CEREBRAL TUMOUR. 

Very little has been added to our knowledge of cerebral tumour in 
children since the exhaustive monograph of Starr; to this I am indebted 
for many of the facts in this chapter. 

Varieties and Location. — Tumour of the brain is not very infrequent, 
and may be seen even in infancy. From this time up to puberty there 
is no period of special susceptibility. In 269 of the cases in Starr's 
collection, in which the nature of the tumour was stated, the following 
were the varieties: 



Tubercle 152 

Glioma 37 " 

Sarcoma 34 " 

Clio-sarcoma 5 " 

Cyst 30 " 

Carcinoma 10 " 

( rumma 1 case. 

269 cases. 

Tuberculous tumours are more often multiple than are other varieties. 
Their most frequent seat is the cerebellum; next to this the pons and 
crura cerebri. They are rarely cortical or central. Glioma is most often 
found in the cerebellum or in the pons, and next in the cortex; but it is 



CEREBRAL TUMOUR. 735 

rarely central. Sarcoma is most frequently in the cerebellum; next to 
this, in the order of frequency, in the pons, the basal ganglia, and the 
cortex. Cystic tumours are either central or cerebellar. Taking the 

rases as a whole, the most frequent seat of tumour in children is, first 
the cerebellum, second the pons, third the centrum ovale. 

Tuberculous tumours are occasionally seen in infancy, but they oc- 
cur most frequently between the ages of five and twelve years. They 
are usually secondary to tuberculosis elsewhere, especially in the lungs 
and in the bronchial lymph nodes. They most frequently start from the 
membranes, rarely being centrally situated, and extend inward, infiltrat- 
ing the superficial portion of the cerebellum or cerebrum. There is 
almost invariably localised meningitis at the site of the tumour; there 
may be adhesions between the dura and pia mater, and the disease may 
extend to the cranial bones. In size, these tumours vary from a small 
pea to a child's fist. They may be softened and broken down at the 
centre, or cheesy throughout. They are the result of a localised tuber- 
culous inflammation, which does not differ essentially from that seen 
in other parts of the body. 

Glioma is not infrequent in infancy. It is probably connected in 
every case with the ependyma of the ventricle. It repeats the structure 
of the neuroglia, being composed of connective tissue and branching cells. 

Sarcoma may be of the spindle-celled or the mixed variety. It grows 
much more rapidly than glioma. The two varieties are not infrequently 
combined in the same tumour — glio-sarcoma. 

Cystic tumours are sometimes sarcomatous in origin, the wall of the 
cyst containing sarcoma cells, and they may also be parasitic, from the 
growth of the echinococcus. They may be found in any part of the 
brain. 

The other varieties of sarcoma, gummata, and vascular tumours, are 
exceedingly rare until after puberty. 

As the tumour grows, secondary lesions are produced in most of the 
cases. These are the result of pressure upon arteries, causing localised 
anaemia, or even cerebral softening; or upon veins, producing congestion 
and oedema. When affecting the middle lobe of the cerebellum, pressure 
upon the venae Galeni may lead to effusion into the ventricles. Localised 
meningitis over tumours superficially situated is the rule, and this may 
be the cause of some of the symptoms. Rarely, cerebral haemorrhage may 
be associated. 

Etiology. — The causes of cerebral tumours are for the most part un- 
known. In a few instances there is a history of definite traumatism. 
Sarcoma or carcinoma may be secondary, and tuberculous tumours are 
probably always so. 

Symptoms. — These may be divided into two groups: first, the gen- 
eral symptoms which are common to tumours of all varieties, and are in- 



DISEASES OF THE NERVOUS SYSTEM. 

dependent of location; Becondly, the local symptoms depending upon the 
situation o( the growth. 

eral Symptoms. — One of the most frequeni is headache. Though 
u varies much in its severity, character, and position, it is rarely absent. 
It lb apt to be Bevere, and may continue for a long period, or it may be 
intermittent. The location of the pain has no definite relation to the 
situation o\' the tumour. It may he accompanied by sensations of tight- 
compression, or tension in the head. It may be associated with 
localised tenderness of the seal]); when this is constant it is a valuable 
symptom for diagnosis, as it often occurs with tumours superficially 
1 orated. 

General convulsions are frequent in the early stage, but separated 
by quite long intervals; they become more frequent and more severe 
as the disease progresses. All degrees of severity are seen, from slight 
twitchings and temporary loss of consciousness, to typical epileptiform 
seizures. They are most common when the growth is rapid and when 
complicating meningitis is present. Attacks of vomiting or of localised 
spasm may for a considerable time precede general convulsions; and in 
a single attack there may be first localised and then general convulsions. 

.Mental symptoms are generally present in great variety and complex- 
ity. There may be only fretfulness and irritability, or a marked change 
in disposition. These symptoms are so frequent from other causes in 
children that they excite no apprehension, unless to them are added 
dulness, apathy, and somnolence. Later in the disease there may be 
attacks of hypochondriasis, or of melancholia; there may be periods of 
wild, almost maniacal excitement; and, finally, the mental impairment 
may approach a condition of imbecility. 

Optic neuritis and optic-nerve atrophy are very frequent, occurring, 
according to Starr, in eighty per cent of the cases. This is only recog- 
nised by the ophthalmoscope, as there may be no disturbance of vision. 
The optic neuritis is generally double, appears earlier, and is more con- 
stant in basal tumours than in those at the convexity, or those centrally 
located. 

Vomiting is very frequent, but diagnostic only when it occurs sud- 
denly without assignable cause, and without nausea or other symptoms 
of indigestion. It is especially significant when frequently repeated, and 
of more importance in older children than in infants. 

Vertigo is often associated with vomiting. At first it is occasional 
and Been upon changing position, but later it may be quite constant, 
especially with tumours in the posterior fossa. 

Disturbances of sleep are frequent. There is usually insomnia, but 
Bleep may he broken by hallucinations, accompanied by attacks of scream- 
ing; rarely is there persistent drowsiness until toward the end of the 
disea 



CEREBRAL TUMOUR. 737 

Local Symptoms. — These depend upon the situation of the tumour, 
but not at all upon its character. Local Bymptoms may be wanting 

entirely, and they may vary much in differenl cases even with tumours 
in the same situation. They are modified by the size and by the rapidity 
of growth, and by the existence of localised meningitis. 

In tumours of the cortex, the meninges are likely to he involved, 
especially with tuberculous and gliomatous growths. The pathological 
process may extend from within outward or from without inward. The 
most frequent general symptoms in such cases are headache, circum- 
scribed tenderness of the scalp, convulsions, and mental symptoms. Op- 
tic neuritis, vomiting, and vertigo are not so common. Tumours situ- 
ated in the frontal lobe, as a rule, present few symptoms and may be 
entirely latent. Irritation of the frontal lobe may extend. to the motor 
area and cause convulsions either local or general ; but not often is there 
paralysis. Tumours of the left side (of the right side in left-handed 
persons) in the third frontal convolution may cause motor aphasia. 

Tumours in the motor convolutions along the fissure of Rolando 
produce the most definite and uniform local symptoms. When situated 
at the upper portion the leg is affected, at the middle portion, the arm, 
and at the lower, the face. Irritative symptoms, such as rigidity or 
clonic spasm, commonly precede for some time the paralysis which re- 
sults from pressure or destruction. These attacks of localised convulsions 
may begin in the face, arm, or leg ; but they usually extend more or less 
rapidly until all three are involved. There is no loss of consciousness, 
but there may follow a slight transient paralysis. Such attacks are 
known as " Jacksonian epilepsy/' and form one of the most diagnostic 
symptoms of cerebral tumour. Localised spasm may be associated with 
anaesthesia or other disturbances of sensation. The paralysis generally 
first affects one extremity — the arm or leg, according to the location of 
the tumour — and afterward it may involve the entire side, including 
the face. 

If the tumour is centrally located, or at the base, hemiplegia may be 
an early symptom from pressure on the motor tract. With cortical 
paralysis there may be associated ataxia and anaesthesia. 

Tumours of the parietal lobe may give no local symptoms. At times 
there are disturbances of muscular sense, tactile sensibility, or sensations 
of pain and temperature. If the inferior parietal lobule of the left side 
is affected, there may be word-blindness, or inability to understand 
written language. 

Tumours of the occipital lobe produce, as the only constant local 
symptom, hemianopsia. This is usually bilateral, affecting the same 
side of both eyes, being on the side opposite to that of the lesion, i. e.. a 
tumour on the right side causes blindness in the left half of both eyes, 
so that the patient sees nothing to the left of a line directly in front 
48 



DISEASES ov THE NERVOUS SYSTEM. 

o( him. Instead of hemianopsia, there may be only irritation and various 
of sight 
Tumours of the temporo-sphenoidal lobe may be latent, or, if on 

the left side, may cause word-deafness, i. e., inability to understand the 
significance oi' spoken language. 

Tumours in the island of Red when situated upon the left side (right 
side in left-handed persons) may cause motor aphasia or disturbances 
o^ speech, [f they are large they may produce symptoms by pressure 
upon the motor tract — hemiplegia or monoplegia. 

Tumours of the basal ganglia cause marked general symptoms, but 
none of a definitely local character. The important symptoms relate to 
the various tracts or bundles of fibres which pass from the cortex through 
the internal capsule. These include the motor and the various sensory 
tracts, the olfactory, auditory, visual, and speech tracts. Any of these 
may be pressed upon, and the nature of the symptoms will depend upon 
the size of the tumour and the extent of the pressure. If only the 
anterior part of the capsule is affected there may be no symptoms; if the 
middle fibres, hemiplegia and disturbances of articulation; if the posterior 
fibres, hemianesthesia. All these may be associated, and any of them 
may be complete or partial. Tumours in this situation are apt to im- 
plicate the cranial nerves. Optic neuritis is quite constant, and appears 
early. Localised or general convulsions are 'rare. 

The peculiar symptoms pointing to tumours of the crura cerebri are 
nystagmus, strabismus, and loss of pupillary reflex, sometimes with gen- 
eral muscular inco-ordination, and a staggering gait. There is usually 
third-nerve paralysis on the side of the tumour, and on the side opposite 
to the hemiplegia with which it is often associated. This variety of 
1 paralysis is quite diagnostic. The symptoms of third-nerve 
paralysis are external strabismus, dilatation of the pupil, and ptosis. 
In these cases optic neuritis appears early. There may be a complicat- 
ing hydrocephalus. While hemiplegia is commonly present with large 
tumours, it may be absent with small ones, or may appear later than 
paralysis of the third nerve. 

Tumours of the pons are quite common. The diagnostic symptoms 
consist in crossed paralysis, the cranial-nerve symptoms being on the 
side of the tumour, and the general motor and sensory symptoms on 
the opposite side. When the seat is the upper half of the pons, the third 
and fifth nerves are apt to be implicated, giving rise to ptosis, dilatation 
of the pupils, external strabismus, trophic disturbances such as ulceration 
of the cornea, and neuralgic pain in the face. Tumours in the lower half 
of the pons involve the sixth, seventh, and eighth nerves, causing internal 
strabismus, contracted pupils, facial paralysis, sometimes deafness, and 
auditory vertigo. Other symptoms associated with tumours of the pons 
are headache, vomiting and optic neuritis; convulsions being rare. 



CEREBRAL TUMOUR. 739 

Tumours of the medulla arc recognised by the involvement of the 
glossopharyngeal, pneumogastric, spinal accessory, and hypoglossal 
nerves. There are difficulty of deglutition, irregular respiration, irreg- 
ular pulse, and vaso-motor disturbances, such as flushing of the face 
and perspiration. There may be projectile vomiting, polyuria or gly- 
cosuria, opisthotonus, difficulty in articulation or in sucking, and in 
protrusion of the tongue. When large, these tumours may produce 
symptoms of pressure upon the motor or sensory tracts — paralysis, or 
partial anaesthesia, with rigidity and exaggerated reflexes. 

Tumours of the cerebellum are especially important, this being the 
most frequent location in childhood. When only one hemisphere is 
affected there may be no local symptoms. Tumours involving the mid- 
dle lobe, or those large enough to produce pressure upon the middle lobe, 
give rise to vertigo and cerebellar ataxia. Vertigo is especially frequent ; 
it may occur with headache. Cerebellar ataxia is different from the 
ataxia due to a spinal-cord lesion, and strikingly resembles that of intoxi- 
cation. It may increase until the patient is unable to walk, although 
there is no loss of muscular power. Vomiting is a frequent symptom, as 
are also optic neuritis, and headache which is usually occipital. When 
there is secondary hydrocephalus, as is not uncommon, mental symptoms 
are present, and there may be enlargement of the head. Opisthotonus 
is occasionally seen, but general convulsions are rare. 

Diagnosis. — The size of the tumour is to be determined mainly by the 
general symptoms, special attention being given to the order of their 
development. A diagnosis as to the nature of the tumour is really not 
of much importance; but some information upon this point may be 
gained from the consideration of its etiology, the rapidity of its growth, 
and the age of the patient. Cerebral tumour may be confounded with 
abscess, tuberculous meningitis, chronic basilar meningitis, and chronic 
hydrocephalus. The symptoms distinguishing tumour from abscess are 
the following: Tumour may occur at any age; without definite etiology, 
excepting when tuberculous; the progress is steady, but generally slow, 
new symptoms being continually added; headache is more constant and 
more severe; optic neuritis more frequent; cranial nerves more often 
involved; mental disturbances more marked; focal symptoms are often 
definite; fever and leucocytosis are absent; duration, six months to two 
years. As compared with the above, abscess is not so frequent, being 
especially rare in infancy ; there is a definite history of traumatism or ear 
disease; progress more irregular; symptoms often intermittent; head- 
ache less severe; mental symptoms less marked; optic neuritis and in- 
volvement of the cranial nerves less frequent; focal symptoms usually 
indefinite; localised tenderness over the scalp more constant; fever and 
leucocytosis present except in the latent period; the most frequent 
complication is acute meningitis. 



7 10 DISEASES OF THE NERVOUS SYSTEM. 

Cases o( tuberculous meningitis which may be confounded with 
tumour arc those of slow course sometimes seen in older children. The 
difficulty in diagnosis is increased by the frequent association of tuber- 
culous tumours with tuberculous meningitis. The main points of dif- 
ference are that in tumour the symptoms are more localised and the 
course generally much slower. Almost every individual symptom, how- 
ever, may be present in the two conditions. 

Chronic- basilar meningitis may produce symptoms almost identical 
with those o( tumour in the posterior fossa. It is, however, confined to 
infancy: hydrocephalus and opisthotonus are much more marked than 
are usually seen with tumour. 

Chronic hydrocephalus may resemble tumour; this occurs so fre- 
quently as a lesion secondary to tumour that the question often arises 
whether there is only hydrocephalus, or there is in addition a tumour. 
Primary hydrocephalus is usually congenital, and commonly attains to 
a greater degree than is seen in secondary hydrocephalus. 

Prognosis. — The prognosis in cerebral tumour, while bad, is not hope- 
less. Cases are occasionally seen which exhibit all the characteristic 
symptoms of tumour, even including optic neuritis, which recover per- 
fectly. These are probably syphilitic, although often no such history 
can be obtained. In other cases, most frequently of a tuberculous na- 
ture, an arrest of the growth occurs and the patient recovers with some 
function of the brain impaired; usually there is loss of vision or some 
paralysis. In most cases, however, the progress is steadily downward 
until death. 

Treatment. — If there is any reason to suspect syphilis, the iodide of 
potassium should be given in large doses and continued for a long period; 
the effect of this drug even in tumours not sv^philitic is sometimes 
beneficial. Starr refers to a case in which symptoms of six months' 
duration, including optic neuritis, entirely disappeared under the use 
of mercury and the iodide. The tumour was supposed to be gumma, but 
an autopsy obtained six months later showed it to be a sarcomatous cyst. 
For a discussion upon the surgical aspect of the treatment of brain 
tumours, the reader is referred to Starr's work on Brain Surgery. 



HYDROCEPHALUS. 

Hydrocephalus, or "water on the brain," consists in an accumulation 
of serum in the cranial cavity. This may be between the dura mater 
and the pia (external hydrocephalus) or in the ventricles of the brain 
(internal hydrocephalus). The former is secondary and is quite rare, 
while the latter is not uncommon. Hydrocephalus may be acute or 
chronic. 

Acute hydrocephalus is secondary to basilar meningitis, which is usu- 



HYDROCEPHALUS. 74 1 

ally of tuberculous origin. The terms tuberculous meningitis and acute 
hydrocephalus are sometimes used synonymously. A moderate distention 
of the ventricles is frequent in all varieties of acute meningitis. The 
amount of fluid in acute hydrocephalus is not great, there being rarely 
more than three or four ounces present. 

Chronic external hydrocephalus except in its mild form is extremely 
rare, and is nearly always a secondary lesion. It may follow meningeal 
haemorrhage, pachymeningitis, or any lesion causing cerebral atrophy. It 
is seen in its most marked form associated with congenital malforma- 
tions of the brain, particularly imperfect development of the hemi- 
spheres. (See Fig. 123.) On incising the dura mater a few ounces, or 



Fig. 123. — Brain in External Hydrocephalus, showing Imperfect Development 
of the Hemispheres. Patient three and a half months old; head measured 20 H 
inches; increase in size, 2 inches in the six weeks before death; symptoms wore typical 
of ordinary internal hydrocephalus. In the picture the small size of the cerebrum 
is best judged by comparison with the cerebellum, which is normal. The hemi- 
spheres were rudimentary; the basal ganglia were normal; the cranial cavity con- 
tained about one pint of fluid. 

sometimes even a pint, of serum may escape. The convolutions are 
somewhat flattened, and may be greatly atrophied. Other lesions are 
found either in the brain or in the dura mater. External hydrocephalus 
may cause enlargement of the head and separation of (lie sutures, and 
in fact most of the symptoms of the internal variety: hut usually it is 
not severe enough to give rise to any decided symptoms. 



742 DISEASES OF THE NERVOUS SYSTEM. 

CHRONIC [NTERNAL HYDROCEPHALUS. 

This is the important variety, and when no qualifying term is men- 
tioned this is the form of hydrocephalus which is always understood. 

Etiology. —This occurs both as a primary and a secondary condition. 
When secondary it is usually associated with tumours of the base of the 
brain or with chronic basilar meningitis, either simple or tuberculous. It 
is in these cases a mechanical condition caused by pressure which oblit- 
erates the openings from the lateral ventricles into the fourth ventricle, 
or the foramen of Magendie. 

The causes of primary hydrocephalus are as yet very little under- 
stood. In a large proportion of the cases the disease is congenital, gen- 
erally beginning in the latter months of intra-uterine life. Some of these 
ire dearly syphilitic. Rickets and hydrocephalus are occasionally 
associated, but so infrequently as to make a definite etiological connec- 
tion between them very doubtful. The rachitic head has been so often 
mistaken for hydrocephalus that an erroneous notion lias arisen as to 
the frequent association of these two diseases. Heredity is a factor of 
some importance; numerous instances are on record where two children 
in the same family have been affected. Hydrocephalus not infrequently 
develops alter successful operations upon spina bifida or encephalocele. 

Lesions. — The difference between the primary and secondary cases is 
chiefly one of degree. The amount of fluid in secondary cases is rarely 
more than three or four ounces. In primary cases it is usually from 
half a pint to one pint, but it may be very great. In one of my own cases 
there Mas removed from the head of a child, who died at four months, 
five pints of fluid. Larger quantities than this have been reported, but 
not so far as I am aware at so early an age. In composition this re- 
sembles the cerebro-spinal fluid. An examination in one of my cases 
showed it to be a clear, translucent fluid, slightly alkaline in reaction, 
specific gravity 1.005, containing sodium and potassium chlorides, alka- 
line phosphates, and a trace of albumin. In some specimens sugar is 
found. In cases of inflammatory origin the amount of albumin is gen- 
erally larger, and the fluid may be slightly turbid. The effusion may be- 
come purulent from accidental infection resulting from operation, from 
rupture, or, as in one of my cases, from infection through the sac of a 
spina bifida with which it was complicated, the process extending to the 
brain through the central canal of the cord. 

The changes in the brain result from the gradual accumulation of 
fluid in the ventricles. The septum lucidum is usually broken down, 
and all the avenues of communication between the ventricular cavities 
are greatly enlarged. The continuous distention results in a gradual 
thinning of the brain substance which forms the ventricular walls; often 
these are found only one-fourth of an inch in thickness, or even less 



CHRONIC INTKRNAL HYDROCKIMIALIS. 



743 



than this, the cortex being a mere shell (Fig. l*il). In our of my 
autopsies (he ependyma <>f the ventricle and (he pia mater were in places 
actually in contact, all of the brain tissue having been absorbed; the 
brain resembled a large 
double cyst. In a ease of 
Peterson's, with the ex- 
ception of a small portion 
of one temporo-sphenoidal 
lobe, all of both hemi- 
spheres had disappeared, 
the cerebellum and basal 
ganglia alone being: 
tact. The brain 
anaemic, and the gray and 
white substance may he in- 
distinguishable. The 
changes are largely me- 
chanical, the microscope 
showing, in my case just 
referred to, only granular 
matter and round nuclei 
evidently from broken- 
down nerve cells. In less 



is always 




Fig. 124. — Vertical Transverse Section of a Brain 
in Congenital Hydrocephalus. From a child 
who died at the age of three weeks. A, distended 
lateral ventricle; B, its descending horn. 



severe cases the changes may be slight. It is, however, always surprising 
to see the amount of compression which the cortex will tolerate without 
interference with its functions, provided the pressure comes gradually. 
The ependyma may be normal, but it is usually somewhat thickened and 
pale, sometimes granular, and may be infiltrated with new cells. When 
infection takes .place an acute ependymitis may be set up. Chronic in- 
flammation of the ependyma is thought to be the essential lesion in many 
of the primary cases, whether of simple or syphilitic origin. 

The bones of the skull are markedly affected; the sutures at the 
vault are widely separated, and sometimes even those at the base. After 
the removal of the fluid the head collapses, giving an appearance which 
has been well likened to a " bag of bones." It should not be forgotten, 
however, that hydrocephalus may coexist with premature ossification, 
in which case the head may be small. In the cases which recover, the 
wide gaps in the skull may be closed by the development of Wormian 
bones; but ossification is often not complete until the fifth or sixth year. 

The most frequent lesion associated with congenital hydrocephalus 
is spina bifida, in which case there may also be a patency of the central 
canal of the spinal cord; more rarely meningocele or encephalocele are 
met with. Sometimes there are deformities in other parts of the body, 
such as club-foot or hare-lip. 



[4 



DISEASES OF THE NERVOUS SYSTEM. 



Symptoms. -Hydrocephalus may exist with a small head. In this 
condition there is usually premature ossification of the cranial bones. 
Four Buch rases have come under my notice, one child having lived to 
be fourteen months old. These children are usually idiotic, and die at 
an early aire, often from convulsions. In such cases other malformations 
o( the brain are frequently associated. 

Hydrocephalus, with the exceptions mentioned, is recognised by the 
increased size of the head. In order to estimate the amount of enlarge- 
ment, it must he remembered that at birth the circumference of the 
normal head is about 14 inches, and at one year from 18 to 19 inches. 
The degree of enlargement in hydrocephalus may be very great. In one 
of my cases, the head at four months measured 24-J- inches. In another 
at ten and a half months, 26J inches. Steiner has reported a remark- 




Fig. 125. — Chronic Hydrocephalus of Average Severity. 
Head of pyramidal shape; showing characteristic expression of the eyes. 



able ease in which the head at eight months measured 32f inches. 
When the enlargement of the head is not great the diagnosis is not so 
Hydrocephalic enlargement is commonly symmetrical and in all 
directions. The head is sometimes globular in outline and sometimes 
pyramidal (Fig. 125). The forehead is exceedingly high and project- 
ing and there is a prominence of the frontal eminences seen in no other 



CHRONIC INTERNAL HYDROCEPHALUS. 745 

form of enlargement. The sutures may be separated from half an inch 
to two or three inches; the fontanel is very large, tense, and bulging; 
the veins of the scalp are enlarged and prominent. In marked ca 
fluctuation may be readily obtained, and the head may even be distinctly 
translucent. 

In the acquired form all these symptoms are less marked, and if ossi- 
fication of the skull has taken place it is often impossible to discover 
any increase in size. The rate of growth of the head varies much in dif- 
ferent cases, and it is the surest measure of the progress of the case. The 
increase in circumference is usually from one to three inches a month. 

The primary cases are for the most part of congenital origin, and the 
child may die in utero. At otJier times the process may have advanced 
so far before birth that puncture of the head is necessary before delivery 
is possible. In perhaps the majority of cases no symptoms are observed 
at birth, or the head is only slightly larger than normal. Usually nothing 
is noticed until the child is two or three months old, when it is discov- 
ered that the head is increasing in size at an abnormal rate. If the 
progress is rapid, other symptoms are soon evident: the infant can not 
hold up his head; he is lethargic, and all his perceptions are dulled, sight 
and hearing included; there may be a general flaccid condition of all 
the muscles of the extremities due to a slight general paresis, but more 
often there is rigidity, which is usually most marked in the legs, but 
sometimes in the arms; the hands are often clenched, with the thumbs 
adducted; the reflexes are exaggerated; the pupils are generally con- 
tracted and equal, though they may be dilated; nystagmus and conver- 
gent strabismus are often present. Convulsions may occur from time to 
time, or may be deferred until near the close of the disease. As the head 
enlarges the body usually wastes, and the disproportion between the two 
may seem greater than it really is. 

Such congenital cases rarely see the end of the first year, and are 
often fate^ during the first six months. The causes of death are 
marasmus, convulsions, and intercurrent disease, rarely rupture of the 
head. 

In the cases which develop more slowly, the symptoms are quite dif- 
ferent. The head may not attain at eighteen months the size reached in 
the other cases at the third or fourth month. The surprising thing 
about many of these cases is that the distinctly cerebral symptoms are 
so few. When the pressure develops gradually, the brain seems able to 
tolerate an almost indefinite amount of it. The more readily the bones 
of the skull yield to pressure the fewer are the nervous symptoms ; 
hence, other things being equal, they are less marked when the disease 
begins before the sutures are firmly ossified than in the later eases. A 
comparatively small amount of effusion may cause very marked symp- 
toms in a child two or three years old, while a much larger amount, in 



746 DISEASES OF THE NERVOUS SYSTEM. 

an infant of b year, may produce much less disturbance. It is for this 
reason thai secondary hydrocephalus causes such striking symptoms, 
although the accumulation of fluid is small. 

Whether the progress of these cases is slow or rapid, the development 
of the children is greatly retarded. Many are not able to support the 
head until two or three years old ; frequently they do not walk until five 
or >i\ wars old. The special senses arc generally not noticeably affected, 
hut intelligence in mosl rases is interfered with — in some only slightly, 
in others very markedly, while some are idiotic. Contractions of the 
extremities are occasionally seen, but usually more of the hands than 
the legs. Sensation is not often affected. The course is a very chronic 
one. From time to time there are exacerbations of the symptoms, and 
even intercurrent meningitis may be excited. 

Prognosis. — Most of the congenital cases are fatal before the end of 
the first year. It is very rare that a hydrocephalic child reaches the age 
of seven years. The process may, however, go on up to a certain age, 
and then cease spontaneously, and the child may go through life with 
a head very much larger than normal and usually with a mental condi- 
tion somewhat impaired. Retrogression of the symptoms is, however, 
never to be looked for. 

Diagnosis. — The most important symptom is the enlargement of the 
head, and this can only be arrived at by careful measurement and com- 
parison with the normal size. The rapidity of growth is quite as impor- 
tant for diagnosis as the fact of enlargement. If the head grows as 
much as an inch a month there can be little doubt. The enlargement 
most frequently confounded with hydrocephalus is that which occurs in 
rickets. In the latter disease it is almost invariably irregular; there are 
prominences over the two frontal eminences and over the parietal bones, 
often with furrows between them; the size of the head is chiefly due to 
thickening of the bones of the skull; the marked prominence of the 
forehead is not seen, and the increase in the bi-parietal diameter is not 
present ; furthermore, there are other signs of rickets. 

Treatment. — If there is any suspicion of syphilis, mercurial inunc- 
tions should be employed, and potassium iodide given internally in full 
Of all the operative measures that have been proposed for this 
condition, and their name is legion, the only one at the present time 
which seems to hold out any reasonable prospect of permanent improve- 
ment is auto-drainage. This consists in establishing a communication 
between one of the lateral ventricles and the sub-arachnoid space. By 
this means the fluid is conducted to a place from which it can be ab- 
sorbed. A considerable number of cases have now been treated in this 
way. The dangers of the operation are considerable, nearly half the pa- 
tients having died as the direct result of it. Of those who have survived, 
a number have shown improvement and a few very striking improve- 



INFANTILE CEREBRAL PARALYSIS 747 

ment, but no complete cures have been reported. Operation i> not to be 
recommended in early eases with rapidly increasing enlargement. The 

best results have been obtained in old cases which have reached a nearly 
stationary condition. 

INFANTILE CEREBRAL PARALYSIS. 

(Spastic Diplegia, Paraplegia, or Hemiplegia.) 

Under the term cerebral paralysis are included several groups of i 
with causes quite dissimilar, but having certain definite clinical features 
in common. While the symptomatology is quite clear, there are many 
questions relating to the pathology that are not yet fully settled, al- 
though much has been added to our knowledge within the last few years. 
Paralysis depending upon cerebral tumour, abscess, or hydrocephalus is 
not included in this chapter. 

The cases of cerebral paralysis may be divided into three groups, 
according as the paralysis depends upon conditions existing prior to 
birth, upon those connected with birth, or upon those of subsequent 
development. 

I. Paralysis of Intra-TJterine Origin. — This is the least frequent con- 
dition. In such cases there is some congenital defect in the brain, due 
sometimes to arrest of development, at others to such intra-uterine lesions 
as haemorrhage or thrombosis. There may be porencephaly, or cysts 
extending deeply into the substance of the brain, sometimes communicat- 
ing with the ventricles. The origin of this condition is for the most 
part unknown. In rare cases the paralysis is due to cortical agenesis. 1 a 
condition in which the brain may seem normal to the naked eye, but the 
microscope shows a complete arrest in the development of the cells of the 
cortex, usually affecting both hemispheres. In still other cases there are 
found gross defects in development in the motor centres of the cortex. 
Such a lesion is shown in Fig. 13T. Cases in which there is conclusive 
evidence of intra-uterine haemorrhage are very rare. 

Symptoms. — In most of the paralyses due to intra-uterine lesions, 
loss of power is only one of the symptoms, and usually not the most 
prominent. It is rare that there is not some mental impairment, and 
usually idiocy is present. The type of paralysis is nearly always diplegic 
or paraplegic. When this is due to arrested cortical development, a 
general flaccidity of the muscles may be seen instead of the rigidity so 
characteristic of the other forms of cerebral paralysis. 

II. Birth-Paralysis. — Cerebral birth-paralysis is due in nearly all 
cases to meningeal haemorrhage. The primary lesions and the early 
symptoms have already been described in connection with the Diseases of 
the Newly Born. The secondary lesions present considerable variety. 



For fuller description, see Sachs' Nervous Diseases of Children. 



748 DISEASES OF THE NERVOUS SYSTEM. 

There may be found (U meningoencephalitis, (2) atrophy and sclerosis 
of the cortex, (3) cysts upon the Burface, (4) secondary degenerations in 
the Bpina] cord. 

1. Meningo- encephalitis. — This lesion is often quite diffuse. There 
is thickening of the pia mater, and it is usually adherent to the brain 
substance The cortex is involved to a variable degree, depending some- 




Fig. 126. — Extensive Atrophy and Sclerosis of the Right Hemisphere. From an 
infant seven and a half months old; probably the result of a meningeal haemorrhage 
at birth (lateral view). History. — Twelve hours after birth was seized with general 
convulsions, which continued for three days. No other symptoms noticed till one 
month before death, when weakness of the left arm was observed. Never held head 
erect. Was plump and well nourished; died from erysipelas. Autopsy. — Pia not 
adherent; a large cyst occupied the region of the occipital and posterior part of the 
parietal lobes, showing in its floor discolouration and pigmentation, evidently from 
an old haemorrhage. Right optic nerve, tract, and crus much smaller than the left. 

what upon the time which elapses between the initial lesion and the 
autopsy. The following were the microscopical changes found by Sachs 1 
in the brain of a child in my wards at the Babies' Hospital, who died 
at the age of one year of measles : The lesions were found everywhere in 
the cortex. The pia was universally adherent, and showed general cel- 
lular infiltration; its blood-vessels showed marked cell proliferation, 
and the veins in the sub-pial space were dilated and filled with blood. 
In the pia dipping in between the convolutions similar changes were 
present. In the cortex few, if any, normal pyramidal cells were found, 

1 The clinical features of this case are quite as interesting as the pathological find- 
ings. The child was a first-born, delivered after a dry labour of forty-eight hours. 
It was asphyxiated, and from the first days of its life it had attacks of convulsions, 
usually repeated many times a day. During one of these convulsions the photograph 
from which Fig. 127 was made, was taken by Dr. Peterson. The child had the symp- 
toms of typical spastic paraplegia — the arms being, however, slightly involved — 
retarded mental development, and convergent strabismus. 



INFANTILE CEREBRAL PARALYSIS. 749 

but in the outer layers were an enormous number of small glia cells. 
Many of the blood-vessels showed a cell-proliferation of their walls. 
There was also degeneration in the pyramidal tracts of the lateral 
columns of the cord. 

2. Atrophy and Sclerosis. — These changes vary much in extent and 
degree. There may be only a circumscribed area in which the convolu- 
tions are small, firmer than usual, and covered with an adherent pia, or 
there may be an atrophy so extensive as to involve a large part of one 
hemisphere (Fig. 126), or sometimes of both hemispheres. Usually the 
lesion is somewhat diffuse over the convexity of both sides, and mueh 
more frequently of the anterior than of the posterior half of the brain. 
Where a depression of the brain exists the space is filled with cerebro- 
spinal fluid, and in many cases there is a deformity of the skull. 

3. Cysts upon the surface may occur alone or in connection with the 
lesions just mentioned. These are usually small, about the size of a 
walnut, but they may cover a large part of a hemisphere. Such large 
cysts are sometimes classed as cases of external hydrocephalus. 

4. Secondary degenerations of the internal capsule and the lateral 
columns of the cord are found in most of the cases associated with ex- 
tensive atrophy and sclerosis, and in many of those in which only me- 
ningo-encephalitis is present. 

Symptoms. — The type of paralysis will, of course, depend upon the 
extent and position of the original lesion. A diffuse lesion is followed 




Fig. 127. — Convulsions in Spastic Paraplegia. 
From a photograph by Dr. Frederick Peterson during an attack. 

by diplegia; one not quite so extensive by paraplegia; one affecting one 
side only, by hemiplegia, or even monoplegia, though this is very rare. 
The relative frequency. of the different forms will vary according to the 
age at which the patients come under observation. According to my 



>0 



DISEASES OF THE NERVOUS SYSTEM. 



own observations, which have been chiefly upon infants, the cases of 
diplegia and paraplegia have outnumbered those of hemiplegia more 
than four to one. My belief is that the great majority of the congenital 
or those duo to haemorrhage occurring at birth, are diplegias or 
paraplegias, and that very many of them succumb during the first two 
: however, the cases of hemiplegia, because of the less serious 
lesion, live much longer. Diplegia and paraplegia will therefore be con- 
sidered as the characteristic typos of cerebral birth-palsy, as the cases of 

hemiplegia do not differ from those due 
to later causes — i. e., the acquired form. 

In the most severe cases that survive 
the symptoms of the early days of life 
there remains some rigidity of the ex- 
tremities, chiefly of the legs, which is 
constant or intermittent, slight or well 
marked. There is often spasm of the 
muscles of the neck and trunk, giving 
rise to opisthotonus. In many cases 
there are frequent attacks of convulsions 
(Fig. 127). The general physical de- 
velopment of the child is often inter- 
fered with, so that he remains small and 
delicate, and perhaps dies of some acute 
disease in early infancy, never having 
been able to sit erect, or even support 
his head. In other cases the general nu- 
trition is not affected, and life may be 
prolonged indefinitely, but usually witli 
some degree of mental impairment. 
This is seen in all degrees; it may be 
so slight as not to be noticed until the 
child is two or three years old, or the 
child may he idiotic. Often these chil- 
dren are not able to stand until they are 
over three years old and do not walk alone 
until they are four or five } r ears old, and 
then with a peculiar cross-legged gait, 
owing to spasm of the adductors of the 
thighs. This may be so great as entirely 
to prevent walking, and while sitting or 
lying the thighs may cross each other. These form the typical cases of 
spastic paraplegia, sometimes called Little's disease (Fig. 128). All the 
reflexes are greatly exaggerated. The arms are much less affected than 
the legs, and in about half the number they are not involved at all. 




Fig. 12n. — Spastic Paraplegia. 
Child two and one-half years old, 
New York Foundling Hospital, 
unable to walk or even to stand 
without assistance. The habitual 
position of the limbs, which is due 
trong adductor spasm, is 
shown in the picture. 



INFANTILE CEREBRAL PARALYSIS 751 

In the milder cases the early symptoms may be overlooked, ami noth- 
ing excite suspicion until the infant is six or eight months old. Ti. 
is then discovered unmistakable muscular weakness; the child docs m»t 
sit up, or even hold up the head when the trunk is supported. Often 
there is observed before this time a tendency to stiffen the body and to 
throw the head backward, owing to spasm of the cervical or spinal mus- 
cles. The muscular weakness is often mistaken for rickets, or regarded 
simply as backwardness. A closer examination usually discloses the pres- 
ence of some rigidity of the extremities, particularly of the legs, and 
exaggeration of the knee-jerks. As the child grows older other symp- 
toms of imperfect development become more and more evident. 

There are changes in the shape of the skull, this being usually smaller 
than normal in all its diameters, or there may be asymmetry. There is 
an arrest of development in the paralysed limbs. These are both smaller 
and shorter than normal. In many cases abnormal movements are seen, 
which may be of an irregular choreic type, or they may be athetoid. 
Epilepsy develops in from thirty-three to fifty per cent of all these 
patients. 

III. Acute Acquired Paralysis. — This is usually of the hemiplegic 
type, although diplegia and paraplegia may in rare instances be met 
with. This group includes cases developing at any time after birth, but 
the great majority of those seen in childhood begin before the fifth 
year. 

Etiology. — The etiology is often obscure. The paralysis sometimes 
follows traumatism. It is occasionally seen in the course of scarlet fever, 
measles, diphtheria, variola, or pneumonia. Much more frequently 
than with any of these diseases it occurs during pertussis, being usually 
the outcome of a severe paroxysm. The frequency with which these 
cases are ushered in with convulsions has led many to assign this as 
the cause of the paralysis. It is probable that the convulsions are more 
often the result than the cause of the lesion. In some of the acute 
inflammatory cases the cause is possibly the same as in acute polio- 
myelitis. 

Lesions. — The lesions of acute cerebral palsy may be grouped under 
three heads: (1) those of the blood-vessels; (2) those of the membranes; 
(3) those of the brain substance. 

1. Lesions of the Blood-vessels. — There may be haemorrhage, em- 
bolism, or thrombosis. Haemorrhage is by far the most important. It is 
usually meningeal, rarely cerebral. It occurs more frequently at the con- 
vexity than at the base, and is often diffuse. Meningeal haemorrhage 
may result from pachymeningitis. It may be due to traumatism, when 
it is also from the dura mater; or from the acute hyperemia accompany- 
ing paroxysms of pertussis, when it may be from the dura or the pia; 
or it may be secondary to thrombosis of the superior longitudinal sinus. 



752 



DISEASES OF THE NERVOUS SYSTEM. 



The association of haemorrhage with sinus-thrombosis is not very in- 
frequent It was found in one of my autopsies upon a patient who died 
of pneumonia. Cerebral haemorrhage is extremely rare, but it occurs 

even in infants; I once 
saw it in one only two 
months old. 

Embolism is rarely 
found unless associated 
with acute rheumatic en- 
docarditis, and then usu- 
ally in children who are 
over seven years old. As 
in adults, the usual seat 
of the embolus is a branch 
of the middle cerebral ar- 
tery. Thrombosis has 
been met with in a small 
number of cases, but is 
extremely rare. 

2. Lesions of the 
Membranes. — These are 
generally the result of 

Fig. 129.— Recent Mkningeal Hemorrhage. Brain an old cerebro- spinal 
of an infant seven months old in the Babies' Hos- meningitis " Sometimes 
pital. A, punctate haemorrhages; B, thrombosed ,-, i p -i -i-,- 

vessels; C, diffuse extravasation. the J m W be ° f syphilitic 

origin. In both, how- 
ever, the process is rarely confined to the membranes; it is a meningo- 
encephalitis. 

3. Lesions of the Brain Substance. — Atrophy and sclerosis are found 
in a large number of the autopsies made upon cases when the paralysis 
has been of long standing. They represent terminal conditions, however. 
They vary in severity and extent, and are followed by secondary degen- 
eration in the cord, as in cases of birth paralysis. There may be the 
same development of cysts of the pia mater, or an accumulation of fluid 
in the arachnoid cavity, these taking the place of the atrophied convolu- 
tions. The nature of the primary lesion in these cases is not always 
cl'-ar. In a certain number of them it is an acute- poliencephalitis, anal- 
ogous, to acute poliomyelitis, and probably due to the same cause. The 
cerebral lesion may be associated with cord lesions or it may occur alone. 
Their nature is considered in the chapter on Poliomyelitis. In other 
a chronic diffuse encephalitis with atrophy is found at autopsy, 
closely resembling the conditions which follow a meningeal haemorrhage 
occurring at birth, yet the children were normal up to the second or 
third year, and there was no acute onset. 




INFANTILE CEREBRAL PARALYSIS 753 

Acute paralysis sometimes occurs for which no explanation can be 
found a( autopsy. An infant with pneumonia was admitted to the 
Babies' Hospital, who had developed, a few days before, typical right 
hemiplegia. It came on suddenly, with convulsions, and involved the 
face, arm, and leg. The arm and leg appeared to be completely para- 
lysed, but in the face the paralysis was incomplete. The paralysis 
had begun to improve somewhat at the time of the child's death, 
which occurred a little over a week after its onset. At the autopsy 
no gross lesion could be discovered. A careful microscopical exam- 
ination was made, and nothing abnormal was found except a slight 
increase of small spheroidal cells about some of the meningeal and 
cortical vessels of the motor area. The frontal and occipital lobes were 
normal. 

Symptoms. — While diplegia and paraplegia are occasionally seen, 
the great majority of cases of acquired cerebral palsy are of the hemi- 
plegic variety. When diplegia and paraplegia occur, it is usually in 
early infancy, and their symptoms and course differ in no wise from the 
birth palsies. We may therefore regard hemiplegia as the chief mani- 
festation of acquired cerebral palsy. 

The onset of the paralysis is almost invariably sudden, with convul- 
sions, which are usually repeated, and in severe cases followed by loss of 
consciousness. In the secondary cases these are generally the only symp- 
toms. In one of my cases the patient went to bed apparently well, and 
awoke in the morning with hemiplegia. Such an onset, however, is very 
exceptional. 

When the paralysis is due to acute poliencephalitis, the onset is usu- 
ally with high fever, vomiting, often convulsions, followed by delirium 
or stupor. These general symptoms continue for a variable time, usually 
two or three days, before paralysis is seen. The temperature in most 
cases is from 101° to 103° F., and the fever sometimes follows, sometimes 
precedes, the convulsions. The loss of consciousness may last for several 
days, and the paralysis is frequently not discovered until consciousness 
is regained. If there is a very extensive lesion there may be diplegia, 
deep coma, and death, but this is very infrequent. Usually the lesion is 
more limited, and the symptoms are those of typical hemiplegia. The 
face sometimes escapes, and if involved it generally soon recovers. The 
paralysis of the arm and leg is at first complete, but may improve rap- 
idly in the course of a few weeks. Disturbances of sensation may be 
present, but are usually of a transient character. After a variable 
period, from one to several weeks, the patient begins to use the paralysed 
extremities, first the leg, afterward the arm, as in adult hemiplegia. 
The convulsions may be repeated for the first day or two, but prolonged 
or continuous convulsions are rare. They may be general or unilateral. 
With lesions of the left side of the brain, speech may be affected, and 
49 



754 



DISEASES OV THE NERVOUS SYSTEM. 



not infrequently in young children when the lesion is upon the right 
side. The reflexes are increased upon the affected side, and a slight 
ankle-clonus may be present. 

After a few weeks the child may be able to walk, dragging the af- 
fected leg. 'The recovery in the leg is sometimes complete, but in most 
;i Blight halt in the gait remains. The arm usually recovers more 
slowlv than the leg, and contractures are likely to develop after a variable 

time, generally two or three years. In 
Fig. 130 is shown a frequent deformity 
of the upper extremity. Contractures 
of the leg lead to various forms of 
talipes, generally equinus, from short- 
ening of the tendo-Achillis. Sometimes 
the arm or the leg recovers so perfectly 
that the case may be regarded as one 
of monoplegia. In old cases the para- 
lysed limbs are atrophied; there is more 
or less rigidity, and the spastic condi- 
tion may be quite marked. I have seen 
this limited to a single group of mus- 
cles in the leg. Aphasia is common in 
right hemiplegias, and it is not very rare 
in those of the left side, because infants 
appear to use both sides of the brain 
with nearly equal facility. 

The mental condition of these chil- 
dren is often normal, in striking con- 
trast with the cases of congenital di- 
plegia. The earlier the paralysis occurs 
the more likely are mental symptoms 
to be present, since we have here not 
only the direct effect of the lesion, but 
an arrested development of some part 
of the brain. Epilepsy is not an un- 
common sequel; it may be of the Jack- 
sonian type, or there may be attacks of 
general convulsions. In other cases 
their- are post-hemiplegic movements of a choreic or athetoid character, 
or irregular inco-ordinate movements. 

Prognosis of Infantile Cerebral Paralysis.— In diplegia and para- 
ph >gi n the outlook is always unfavourable. A very large number of these 
wrhich are due either to intra-uterine or birth lesions never reach 
the third year, hut die in infancy from marasmus or acute intercurrent 
. Those who survive usually show serious mental defects, and 




Fig. 130. — Deformity of Left 
Hand the Result of Contra ct- 
ctbes following an attack of 
Hemiplegia Four Years Be- 
fore. Child seven years old. 



INFANTILIS CEREBRAL PARALYSIS. 755 

many are practically helpless on account of the extreme Bpastic condition 
of the muscles of the extremities. 

In hemiplegia the prognosis is much more favourable. In most of 

these cases the paralysis is of the acute acquired variety, and the later 
the period of onset, the less likely is the brain to be seriously damaged. 
In some of these patients complete recovery takes place: in others the 
residual paralysis is so slight as to be easily overlooked except on careful 
examination, the occurrence of epilepsy being perhaps the first thing 
which leads one to suspect that a previous paralysis has existed. The 
great majority of children who have suffered from infantile cerebral 
palsy have some degree of permanent paralysis and usually some deformi- 
ties from contractures, the extent of both varying, of course, with the 
severity of the primary lesion. In all cases seen in young infants it is 
exceedingly difficult to give a prognosis in regard to future mental de- 
velopment. As a rule, the impairment is directly proportionate to the 
extent of the paralysis and its intensity. 

Diagnosis. — The diagnosis between the congenital and acquired forms 
of cerebral palsy is of no great practical importance, and it may he im- 
possible; for the symptoms in congenital cases are often not sufficiently 
marked to attract attention until children are old enough to sit alone or 
to walk. 

It may be quite difficult to distinguish cerebral paralysis from infan- 
tile spinal paralysis. The history of an acute onset, the atrophied limbs, 
the deformities, and the absence of sensory disturbances, may be found 
in both conditions. Spinal paralysis is, as a rule, monoplegic, and often 
affects but a single group of muscles. Cerebral paralysis is either di- 
plegic or hemiplegic in character, and even though only a leg or an arm 
may seem to be affected, a critical examination will usually reveal the 
fact that the other limb of the same side has also suffered. The presence 
of rigidity and exaggerated reflexes is quite as important evidence of 
this as loss of power. The electrical reactions, however, are conclusive ; 
the reaction of degeneration is absent in cerebral paralysis, while it is 
present in spinal paralysis. 

Simple as the differentiation may seem in most cases, the mistake is 
frequently made of confounding cerebral diplegia, particularly of the 
flaccid type, with rickets. Cases of acute acquired paralysis at the onset 
may be mistaken for acute meningitis, but early loss of consciousness, 
the early development of the paralysis, its permanent character, and the 
shorter duration of the acute symptoms, usually distinguish these cases 
from those of meningitis. The only definite means of differential diag- 
nosis is by lumbal- puncture; this gives negative results in cerebral paral- 
ysis and positive results in meningitis. 

Treatment. — The course and the result of cerebral paralysis depend 
upon the extent of the injury to the brain, its nature, and the age at 



756 DISEASES OF THE NERVOUS SYSTEM. 

which n is Inflicted — all these being conditions which are beyond the 
power o( the physician to modify or control. The treatment of cerebral 
palsy is therefore extremely unsatisfactory. For the congenital cases 
practically nothing ran be done, except for the deformities and compli- 
cations. The acquired cases during the acute onset are to be managed 
like all other cases of acute cerebral congestion or inflammation — abso- 
lute rest, ire to the head, and bromides. Electricity is not to be used 
in early eases, and little or nothing is to be expected from it in the late 
ones. Much can be accomplished in an educational way for the mental 
derangements resulting from cerebral palsy. An important part of the 
treatment relates to the deformities. Many of these may be prevented 
by the early use of orthopaedic apparatus. Serious deformities in old 
- - may he greatly benefited by tenotomy or myotomy, followed by 
the use of suitable apparatus. Division of the posterior nerve roots has 
been performed for the relief of extreme spasticity with, in some cases, 
very striking benefit. Epilepsy is to be treated as when it depends on 
other causes. 

MENTAL DEFECTS. 

DEFICIENCY, IDIOCY, IMBECILITY. 

All grades of mental defects are seen in children. While the terms 
above used characterise the chief clinical types, it should be remembered 
that these shade into each other by almost imperceptible degrees. They 
may be the result either of arrested development or of disease or injury 
of the brain. 

The backward child does not belong in this group, although often 
placed here by parents or teachers. Such children may present many 
mental peculiarities, but differ from the normal standard chiefly in the 
slowness with which the mental functions are developed, the most notice- 
able of these being speech. It is backward children and those who pre- 
sent the milder grades of mental defect that are of the greatest clinical 
interest and importance, for in them the mental condition often depends 
upon some physical cause which time and proper treatment may remove. 
Common causes are defective sight or hearing, severe early rickets, pro- 
longed malnutrition, etc. 

Following somewhat the classification of Ireland, the mental defects 
of children may be divided into the following groups: 

1. Those depending upon such congenital conditions as porenceph- 
alies, arrested development of the brain as a whole, or of some portion, 
particularly the frontal lobes. An excellent illustration of this class of 

«n in Fig. 137. Another variety is known as "Agenesia cor- 
tical)'^" described elsewhere. 

2. Those associated with external or internal hydrocephalus. 



MENTAL DEFKCTS. 



757 



3. Those associated with microcephalus, either with or without pre- 
mature ossification of the cranial hones (Figs. 134 L36). 

I. The paralytic eases, including the varieties which occur m the dif- 
ferent forms of cerebral paralysis, the greater pari of which are due to 
meningeal haemorrhage at birth, and which are clinicall} associated with 

Various Types of Mental Defects. 




* 





Fig. 131. 



Fig. 133. 



Fig. 132. 
Figs. 131-133.— Mongolian type. 
Fig. 131. — Six months old; died at twenty-two months; could not hold up the head, 
or understand anything. 

Fig. 132. — Boy six and a half years old; did not walk or talk till four years old; now 
quite intelligent, but not normal. 

Fig. 133. — Girl four years old; mental development like that of a normal child of two 
and a half years; walks very awkwardly. 





Fig. 134. 



Fig. 135. 




Fig. 136. 



Fig. 134. — Boy twelve years old; microcephalic; walked at about four years; can read 
and write; development like that of a normal child of eight years. 

Fig. 135. — Microcephalic, seven years old; understands most of what is said; can not 
talk intelligibly. 

Fig. 136. — Girl of eight years; imbecile; can not walk without help. 

Note that the expression in 132, 133, and 134 is not due to adenoids; 132 and 134 
have had them removed. 



spastic diplegia or paraplegia; a smaller number are associated with 
acquired cerebral paralysis, most frequently following meningeal haem- 
orrhage. 

5. Those of inflammatory origin. They follow cerebro-spinal menin- 
gitis and acute porencephalitis. 

6. Those associated with epilepsy, in which the condition is a result 



758 



DISEASES OF THE NERVOUS SYSTEM. 



of changes in the brain produced by the repetition of the epileptic 

Mongolian Idiocy. — This is a form Characterised by a peculiar 

Chinese type of skull and lace, with marked backwardness in physical 
ami mental development (Figs. 131-133). The head is somewhat flat- 
tened from before backward; the nose rather broad and flat: hut the 




Fig. 137. - Abbested Development of the Frontal Lobes of the Brain, Particu- 
larly of the Richt Side. From an idiotic child twelve months old. 1 

striking thing is the narrow palpebral fissures which have a down- 
ward inclination toward the nose. These patients almost always have 
the mouth open ; and the facial expression like that due to large adenoids 
may lead to the suspicion that this is the only condition present. The 
mouth breathing is however, due rather to the peculiar conformation of 



1 A microscopical examination by Dr. Martha Wollstein showed the cortex in the 

affected region to be only one-third the normal thickness; the cortical layers were ill— 

defined; there was a striking absence of the characteristic nerve cells, both the large 

and small pyramidal cells being few in number. There was no growth of connective 

The white substance was normal, as were also the dura and pia. 



MENTAL DEFECTS. 759 

the base of the skull, and the anterior projection of the bodies of the 
upper cervical vertebrae. The Mongolian type is seen in all degrees of 

severity. In early infancy these children may present no striking pe- 
culiarities except in facial expression, and a general backwardness in 
physical development. Dentition is delayed; they may not s i t alone 
until the age of eighteen months or two years, and frequently do not walk 
or talk intelligently until they are four or five years old. In the milder 
forms they are often regarded simply as very backward children. In the 
more severe forms the mental defect may be great. Their resistance is 
feeble, and many die in early childhood. Little is known of the etiology 
of this condition. Cases occur in all classes of society, and when other 
children in the family are quite normal. 

8. Amaurotic Family Idiocy. — This name, proposed by Sachs, indi- 
cates the prominent features of the malady, which is not a very rare one. 
Xothing is known of its etiology except that nearly all the recorded cases 
have been in the Jewish race. Two, and sometimes three or four chil- 
dren in succession have been affected in the same family. The first 
S} r mptoms are usually noticed between the sixth and tenth month, up to 
which time the infant has generally appeared normal. At first it is only 
noticed that the child is making no progress in his development. He 
does not gain in ability to sit up or use his muscles in other ways. He 
lies quietly, does not respond as he once did, and takes less interest in 
his surroundings. After a few weeks it is clear that the child, instead 
of advancing, is actually retrograding, both physically and mentally. 
His muscles become so weak that he can no longer sit up or even hold up 
his head. Closer observation shows that vision is becoming less and 
less distinct. The child no longer recognises the faces of friends or 
objects shown him. Finally, he becomes dull, apathetic, and quite in- 
different to his surroundings, and it is evident that he can not see at all. 
In the early stages the muscles are usually weak and flaccid ; later there 
*is rigidity, with increased knee-jerks and often marked spasticity. There 
may be general convulsions. The characteristic features of the disease 
are revealed by the ophthalmoscope. There is a milky-blue or white area, 
with a bright, cherry-red centre, occupying the place of the macula hi tea, 
and with this there is also atrophy of the optic disc. The ocular changes 
are symmetrical. The disease is progressive, accompanied by marked 
wasting, and usually fatal within a year from the time when the first 
symptoms are seen; but occasionally the blind, helpless child may live 
for two or even six years. The essential lesion consists in degenerative 
changes of the ganglion cells of the central nervous system. The changes 
are most marked in the cerebral cortex, but are widespread, and hardly 
a normal ganglion cell may be found. The outlook is absolutely had, all 
cases terminating fatally. 

9. Both sporadic cretinism and chondro-dystrophy have many symp- 



760 DISEASES OF THE NERVOUS SYSTEM. 

tome suggesting mental defects, but they do not strictly belong in this 
category. They are considered separately later. 

In addition to the etiological factors belonging to the different con- 
ditions above described, the influence of heredity is to be considered; 
there may be hereditary nervous diseases, alcoholism, syphilis, or some 
other vice of constitution. Intermarriage among blood relations is one 
of the causes most frequently assigned; but after an exhaustive study of 
the question, 1 1 nth reaches the conclusion that this view is not supported 
by the fads. 

Diagnosis. — Certain types of mental defect may easily be recognised 
after the age of three or four years, especially the more marked forms 
when they are due to the graver cerebral lesions — hydrocephalus, micro- 
cephalia, various cerebral palsies, amaurotic idiocy, etc. In the milder 
forms and in infancy, however, this is not so easy a matter; it is often 
impossible without a considerable period of observation to distinguish 
a backward or peculiar child from one who has some serious mental 
defect. 

To appreciate the abnormal, one must be familiar with the mental 
and physical development of healthy children. A normal infant of 
average muscular development can usually support the head steadily be- 
fore five months old, often at three months; he can usually sit erect at 
eight or "nine months, and stand with assistance at twelve or thirteen 
months. Toys are held and usually handled with facility at five or six 
months. The recognition of the nurse or mother comes at about the same 
time. Usually the first distinct words are pronounced about the end of 
the first year, and at two years most children put words together in 
short sentences. Variations of a few months from the averages above 
mentioned can not be considered abnormal. 

To determine whether an abnormal mental state is simply the result 
of poor general nutrition, or is dependent upon actual disease or imper- 
fect development of the brain, is frequently a matter of the greatest 
difficulty. The backward infant is usually distinguished chiefly by the 
things which he does not do; while with those who are deficient not 
only are the proper signs of development wanting, but many new and 
peculiar symptoms may be; observed. The backward child may not sit 
alone until he is twelve or fifteen months old, and may not walk until 
he is two and a half years old, but the cerebral development is in most 
proportionate to the physical condition. Speech may be so delayed 
that the first \yov<\> do not come until two years, and short sentences not 
until three years old, and yet in understanding what is said to and done 
for him, the child may seem bright and bis development steady and pro- 
gressive, although slow. 

All children whose development is delayed should be examined for 
local signs of cerebral disease; the symptoms mentioned under the vari- 



MENTAL DEFECTS. 761 

0116 heads of early hydrocephalus, meningeal haemorrhage, and cretinism 

should be SOUght. Sighl and hearing should be tested, and the eves. 

if possible, examined with an ophthalmoscope; the co-ordination of the 
hands should be tested in various ways; the reflexes examined, and gen- 
eral rigidity or slight paralysis noted, also the muscular power in the 

trunk, neck, and extremities. Many children who are mentally deficient 
do not show any disturbances of nutrition during the first year. The 

growth of the body in height and weight may be quite normal: although 
this is rarely true of the muscular power. Some of them show marked 
signs of backwardness in physical development, and in nearly all there 

arc some other striking symptoms. Among the most frequently noticed 
arc: drooling, an open mouth, a protruding tongue, a fixed, aimless stare, 
the production of some inarticulate sounds, which are usually peculiar 
to the child and may he repeated many times a day. Occasionally there 
are sharp screams without any evident cause, also irregular, aimless 
movements of the hands. Objects are not properly held, and if grasped, 
they are soon dropped by an infant of twelve or fourteen months as by 
a normal one of three or four months. The child does not recognise his 
bottle or his nurse. Nystagmus is often present : and- there may he ill- 
defined attacks of a convulsive nature, or typical convulsions. The in- 
fant is not attracted by bright colours or toys, and, in short, seems dull 
and unresponsive to every mental impression. 

An accurate diagnosis usually carries with it the data for a definite 
prognosis. Few misfortunes which can befall a family are worse than 
to have a mentally defective child, and the physician's opinion is sought 
early and eagerly as to the probable outlook for all children who are 
suspected of being in any way abnormal. The possibilities of error in the 
early years are great, and much needless suffering is often caused to 
parents by an erroneous opinion. It is the experience of all who see 
many of these children, that some who were regarded at the age of three 
or four years as seriously defective, have in the end turned out to he 
entirely normal. One should therefore always put tin 1 best possible in- 
terpretation upon the facts. The amount of improvement which takes 
place in many of these cases is most surprising. The above statement 
applies, of course, chiefly to children in whom there an- no evidences 
of gross cerebral lesions. The deviations from what is normal are many 
and wide, and careful observation for a long period is necessary before a 
child is pronounced idiotic or even feeble-minded. 

Most cases of idiocy exhibit to a greater or less degree the stigmata 
of degeneration. In an examination of 517 idiots by Howe, there was 
found blindness in 21 : deafness in 12; some defect of the nose or mouth, 
such as hare-lip, high palatal arch, or cleft palate, in 23 eases: and some 
deformity of the hands or feet in 54 cases; while in 96 there was paral- 
ysis of one or more limbs. 



762 



DISEASES OF THK NERVOUS SYSTEM. 



Treatment. — The problem is essentially an educational one, and for 
such education special teachers and often special schools are indispensa- 
ble. With such advantages it is surprising to see what can he accom- 
plished with many children who have a severe grade of mental defect. 
To furnish a proper means for educating these children is a duty of the 
State, and up to the present time very inadequate provision has been 
made for them. Except in the mild forms, defective children are better 
trained and educated in institutions than in the home, and parents 
should he urged to place them in institutions whenever practicable as 
soon as they have passed the age or development of infancy. 

CHONDRO-DYSTROPHY. 

(Achondroplasia — Congenital or Foetal Rickets.) 

This rather rare condition is the cause of some of the most marked 
examples of dwarfism known. It was recognised as an abnormality by 
the early Egyptians and has figured in art in various ways since that date. 




Fig. 138. — Skull in Chondro-dystrophy, Showing Frontal Prominence and Prog- 
nathism. Girl six years old. 



Paintings show that many of the old court jesters were of this type. 
Because of their striking appearance, these dwarfs have always excited 
much curiosity and interest. 

The causes of chondro-dystrophy are unknown ; only in rare cases 

mv hereditary connection been traced. The pathological process 

begin- in foetal life and consists in a disturbance of the normal ossifica- 



CHON DRO-D YSTROPHY. 



763 



tion of primary cartilage. It affects endochondral ossification only, never 
intra-membranous ossification. The flat hones and the vertebrae there- 
fore escape, while the hones of the extremities Buffer most. The dis- 
ease does not affect bones which are cartilaginous or almosl entirely so 
through the greater part of intra-uterine life. One of the most striking 
changes in the skull is the synostosis or early ossification of the tribasilar 
bone; this is formed of two parts of the sphenoid and the sphenoidal 
process of the occipital bone. Normally this ossification does not take 
place until adult life; in children with chondrodystrophy it often begins 
in utero. This prevents a normal expansion at the base of the skull, and 
the brain, as it grows, is thus crowded upward and forward, causing the 
great prominence of the forehead (Fig. 138). The upper jaw appears 
very prominent on account of the depression at the root of the nose. 

In the long bones there is a marked interference with the normal 
row-formation of the proliferating cartilage cells, which may be seen in 
all degrees. In some cases a periosteal lamella pushes its way between 
the epiphysis and the diaphysis, still further restricting the growth of 

the long bones. As bone formation 
beneath the periosteum goes on 
normally, the bones in this condi- 
tion are thick as well as short. 





Fig. 139. — Normally Developed Long 
Bones of a Fcetus Compared with 
Those of Chondro-dystrophy. (Spill- 

mann.) 



Fig. 140. — Chondro-dystuoph y — Infan- 
tilis Figure. (Marie.) 



Symptoms. — The majority of children suffering from this condition 
are either born dead or die shortly after birth. Those who survive are 
delicate during infancy, but afterward may become strong and healthy. 
The most striking thing about their appearance is the very short legs 
and arms as compared with the length of the body. At birth the arms 
in many cases do not reach to the waist line, and the length of the body 
may be less than the circumference of the head. The epiphyses appear 



764 



DISEASES OF THE NERVOUS SYSTEM. 



somewhat enlarged, the abdomen is prominent, the skin of the extremities 
is in deep folds, the soft parts seeming to be much too abundant for the 

shortened hones (Fig. 110). In infancy these children are often quite 
fat. The facial expression is characteristic. There is usually a deep 
depression and flattening at the base of the nose, with a very marked 
prominence o( the forehead. The head may not only seem large, but by 
measurement may he one or even two inches above the normal average. 
An erroneous diagnosis of hydrocephalus is often made in the early 
stage. Dentition is slightly later than normal, but not more so than is 
seen in moderate rickets. Marked relaxation of the ligaments and rather 
feeble muscular power often delay walking until the third or fourth year. 
If the head is large, the fontanel may not close till the fourth or fifth 
year. The appearance of the fingers is quite characteristic, causing 
the so-called " trident hand." The 
fingers are very short and of nearly 
equal length, and an angular sepa- 
ration is seen at the second joint 
(Fig. 141). 





Fig. 141. — Characteristic Hand of 
Chondrodystrophy. (Marie.) 



A B 

Fig. 142. — A. Normally Developed Boy, 
Age Eight Years. B. Typical Chon- 
dro-dystrophy, Age Eighteen Years. 
(Marie.) 



Although not normal in their mental development, these children are 
far from being feeble-minded. They are often several years behind the. 
normal in speech and in most intellectual efforts. The average patient 
is able to read and do many ordinary things, but throughout life always 
remains somewhat peculiar, and on critical examination is found to be 
subnormal in his mental growth. These dwarfs are good-natured, often 
amusing, easily controlled, and frequently live to a great age. With 
advancing years the figure assumes a very peculiar and characteristic ap- 
pearance. The prominent hips, with the marked lordosis, shortened 



SPORADIC CRETINISM. 7(55 

extremities, and late bowing of the legs, present a striking picture (Fig. 
142). The maximum heighl attained is often not more than three and 
a half or four feet. Although while young of feeble muscular power, 
later in life they often become very muscular. When adult life is reached 
the sexual powers are normal; if the women become pregnant, Caesarian 
section is almost always required on account of deformity of the 
pelvis. 

In infancy, chondrodystrophy is often confounded with rickets, hy- 
drocephalus, and cretinism ; but its features are so characteristic that the 
mistake can hardly be made if the child is carefully examined. No 
known treatment has any influence upon the condition. The use of the 
thyroid extract is entirely without effect. 

SPORADIC CRETINISM. 

{Cretinoid Idiocy ; Myxedematous Idiocy.) 

Since the early description of this disease by Fagge, in 1871 and 
1874, numerous cases have been published in England, on the continent 
of Europe, and in America, showing that sporadic cretinism is not con- 
fined to any country. While the condition is relatively a rare one, since 
it has been generally recognised it is found to be much more common 
than was formerly supposed. 

Etiology. — It is now well established that this condition depends 
upon the absence of the internal secretion of the thyroid gland. In a 
series of sixteen autopsies collected by Fletcher Beach, the thyroid gland 
was absent in fourteen and the seat of bronchocele in two. The symp- 
toms closely resemble the myxcedema of adults which follows the removal 
of the thyroid. Regarding the causes which destroy the thyroid gland 
or abolish its functions little is as yet known. In most cases it is prob- 
ably a congenital condition. In some instances it has followed acute 
disease. In a certain number of cases sporadic cretinism is associated 
with goitre. As a rule, only one case occurs in a family, the other mem- 
bers of which present nothing abnormal in mental or physical devel- 
opment. 

Symptoms. — The symptoms of cretinism in most cases make their 
appearance during the first year, but are sometimes so slight as not to 
be noticed until children are two or three years old, and exceptionally 
not until the seventh or eighth year. The general appearance of the 
cretin is striking, and so characteristic that when once seen the disease 
can hardly fail to be recognised (Figs. 143, 144, and 146). The body is 
greatly dwarfed, and children of fifteen years are often only two and a 
half or three feet in height. All the extremities, the fingers and the toes, 
are short and thick. The subcutaneous tissue seems very thick and 
boggy, but does not pit upon pressure like ordinary oedema. The facies 



,lu> 



DISEASES or THE NERVOUS SYSTEM. 



is extremely characteristic: The head seems large for the body; the fon- 
tanel is open until the eighth or tenth year, and it may not be elosed 
even in adults; the forehead is low and the base of the nose is broad, so 
that the eyes are wide apart ; the lips are thick, the mouth half open, 
and the tongue usually protrudes slightly; the cheeks are baggy, the 
hair coarse, straight, and generally light-coloured. The teeth appear very 
late — in one of my cases none were present at two years — and are apt 
to decay early. 

Fatty tumours are quite constant in older children, although they are 
often wanting in infantile cases. They are seen in the supra-clavicular 
region, just behind the sterno-mastoid muscle, sometimes in the axilla, 
or between the scapulae, and sometimes in other parts of the body. In 
distribution they are apt to be symmetrical, and are usually about half 
the size of a hen's egg. The neck is short and thick. In rare cases there 
may be a slight depression corresponding to the location of the thyroid 

gland. The chest is not deformed. 
The abdomen is large, pendulous, and 
resembles that of rickets. An umbilical 
hernia is almost always present. The 
skin is dry, perspiration scanty, and 
eczema is common. The voice is hoarse 
and rough. Patients often do not walk 
until they are five or six years old, and 
then they waddle in a clumsy way. All 
the movements of the body are slow and 
lethargic, and everything indicates men- 
tal and physical torpor. The rectal 
temperature is usually subnormal. I 
had once an opportunity to observe an 
attack of acute bronchopneumonia in 
one of these cretins two years old. The 
symptoms and physical signs were typi- 
cal, but during the greater part of the 
disease the rectal temperature fluctu- 
ated between 95° and 98.5° F. Only 
once was a temperature above 99° F. 
recorded. On account of their low tem- 
perature and torpid condition these pa- 
tients are very sensitive to cold. The 
mental condition is always impaired, 
and they are often idiotic. Speech is 
acquired late and in some cases not at all. Cretins are dull, placid, and 
good-natured, rarely troublesome or excitable; and when fifteen or eight- 
een years old they appear like children of two or three years. There is 




Fio. 143.— A Ttpical Cbbtin; Two 
and a Half Years Old. A pa- 
tient in the Babies' Hospital. 



SPORADIC CRETINISM. 



767 



an absence of development of the sexual organs, and almost invariably 
they suffer from chronic constipation. 

Diagnosis. — The diagnosis is usually easy, although the early i 
are sometimes miscalled rickets. The low temperature, the facial ex- 
pression, the torpor, and the fatty 
tumours are enough to differentiate 
the two diseases. 




j;v- 




Fig. 144.— Dr. J. P. West's Case of Cre- 
tinism, Seventeen Months old, Be- 
fore Treatment. 



Fig. 145. — After Six Months' Treat- 
ment with Thyroid Extract. 



Prognosis and Treatment. — There is little tendency to spontaneous 
improvement. Many of these patients die in childhood, but a few live 
to adult life. Until within the last few years they were considered hope- 
less. The thyroid extract is a specific remedy for this disease. In many 
cases the improvement is truly remarkable (Figs. 144-147). After a 
few months' treatment the entire appearance of the child is changed. 
The idiotic expression of the face is lost; the thickening of the skin 
and subcutaneous tissues disappears; there is a marked increase in 
height and in the circumference of the head; muscular power is rapidly 
developed, so that many soon become able to walk; and progress is seen 
in dentition, and in some older girls in the establishment of menstrua- 
tion. Intellectual progress is much slower than physical changes; how- 






DISEASES OF THE KERVOUS SYSTEM. 



nearly all the children become brighter and more intelligent and 
learn to speak. 

The ultimate result? vary with the grade of the affection and the 
time when treatment is begun. I have under observation several cretins 
who I :i treated from eight 

to twelve years. Although many of 





Fig. 146. — Dr. J. W. Coyxl 

TwEXTY-THREE Mo.VTHs OlI>, BEFORE 

Treatment. 



Fig. 147. — Aftz 

mext with Thyroid Extract. 



- children seem quite intelligent and are able to attend school, they 
are without exception below other children of their ages in mental and 
physical development. Complete recovery I have not seen : but there 
seems to be no reason why it might not occur if the thyroid were begun 
in early infancy and faithfully continued. If the thyroid is omitted, re- 
- occur in a few months, even in cases well advanced toward 
recovery. 

Most of the thyroid extracts on the market are prepared from the 
glands of the sheep. There is little doubt that the fresh glands are more 
active than the extracts prepared from them : but they are difficult to 
obtain. A reliable extract should be given if results are to be expected. 
The thyroid extract of Burroughs and Wellcome I have found to be more 
satisfactory than many of those on the market. Of this half a grain 



INSANITY. 769 

may be given once or twice a day at first ; after the child becomes some- 
what accustomed to it the daily dose may be gradually increased to five 
or six grains. Some disturbances arc often seen a! the beginning of 
the treatment — perspiration, marked irritability, and sometimes a rise 
in temperature — but these soon pass off. For old cases at least five 
grains daily should be given for an indefinite period. 



INSANITY. 

Insanity is so special a subject that all that will be attempted here 
will be to mention the most frequent varieties seen in early life, with the 
important etiological factors which operate at this period. For a full 
discussion of the subject the reader is referred to works upon insanity. 

Insanity is distinguished from idiocy in that it affects a mind previ- 
ously sound ; however, the two conditions may be associated. Undoubted 
cases of mental disease have been observed before the seventh year, but 
they are extremely rare. From this time up to puberty, however, nearly 
all the varieties seen in adult life occasionally occur, but they are very 
infrequent even at this period. The form which insanity in childhood 
most frequently assumes is mania. 

Etiology. — Insanity is sometimes seen as a sequel of one of the infec- 
tious diseases, more often typhoid fever than any other, although it may 
follow measles, scarlet fever, diphtheria, or variola. Another cause is 
masturbation, although its effect is much more frequently seen after 
puberty than before. Hereditary syphilis is sometimes the cause of de- 
mentia, which comes on about the fourth or fifth year, or even later. 
Alcoholism, epilepsy, insanity, or other nervous diseases in the parents 
are important causes. Prolonged or continuous mental strain, the result 
of overwork in school, is a cause of considerable importance, especially in 
girls about the time of puberty. As exciting causes may also be men- 
tioned various reflex conditions, such as intestinal worms, phimosis, delay 
in the establishment of menstruation, and abnormal conditions of the 
nose and throat; these, however, can not have much influence except 
where the predisposition is a strong one. Insanity may be associated 
with or may follow hysteria, chorea, or epilepsy. It has sometimes fol- 
lowed injury to the brain, acute meningitis, and occasionally other forms 
of brain disease. 

Symptoms. — Certain forms of insanity are practically never seen in 
children, such as paranoia, acute dementia, paretic dementia, periodic 
or circular insanity, and cataleptic insanity. 

Mania is one of the most frequent forms, and is the most common 
variety of post-febrile insanity. Its symptoms may be quite intense, but 
are usually of short duration, lasting but a few days or weeks. In rare 
cases it may continue for months, and it may even be permanent. 
50 



770 DISEASES OF THE NERVOUS SYSTEM. 

Melancholia is not uncommon. It is seen as a result of prolonged 
mental strain in school, it may be due to fear of punishment, and some- 
times may follow masturbation. It is usually associated with some very 
marked disturbance of the general health. It shows itself, as in the 
adult, by fits of depression, self -mutilation, and even by suicidal ten- 
dencies. 

Epileptic insanity may follow epilepsy in children who were pre- 
viously mentally sound, in whom it may take the form of true epileptic 
dementia, or there may be attacks of mania which occur in the place 
of an epileptic seizure or follow such a seizure. Transitory attacks of 
fury or frenzy coming on without apparent cause should always suggest 
the possibility of epilepsy. 

Other forms which insanity assumes in early life are : transitory psy- 
choses, such as delirium, night-terrors, attacks of sobbing or weeping, 
sometimes from fright; moral insanity, as shown by perversion of the 
moral sense and by various vicious tendencies; morbid impulses, which 
may be homicidal or sexual, or a disposition to thieving, lying, pyro- 
mania, etc. ; morbid fears, of which there may be an almost endless 
variety. These are sometimes associated with a low state of physical 
health; this, however, is usually not the case. 

Prognosis. — On the whole, insanity in childhood has a better prog- 
nosis than in the adult. In most of the cases of mania, melancholia, the 
various transitory psychoses, or the choreic and hysterical forms, recovery 
occurs with proper treatment. The outlook for the other varieties is 
much worse, especially in those in which there is a strong hereditary 
tendency to mental disease. 

The treatment is to be conducted along the same general lines as in 
adults. 

THE STIGMATA OF DEGENERATION. 

These marks are of much importance in relation to the different forms 
of nervous disease in children, especially epilepsy, idioc}', and insanity. 
They are of great value in determining existing nervous disease, or as 
showing latent neuropathic tendencies. 

The physician should be familiar with these various signs in order 
that he may connect them with each other and refer them to their 
proper source, and at the same time, by appreciating their significance, 
be able to advise parents with regard to the care, education, mode of 
life, and occupation of children, in whom to a greater or less degree these 
signs may be present. These stigmata are not of equal importance as 
marks of degeneration. Some of them, such as facial asymmetry and most 
of the deformities of the palate, are always to be so regarded ; the speech 
defects are often so, while many of the others may or may not be, ac- 
cording to their association. The stigmata are divided into anatomical. 



DEAF-MUTISM. 771 

physiological, and psychical. The following is the classification given 
by Peterson : 

Anatomical Stigmata. — Cranial anomalies: Facial asymmetry; de- 
formities of the palate ; anomalies of the teeth, tongue, lips, or nose. 

Anomalies of the eye: Flecks on the iris; strabismus; chromatic 
asymmetry of the iris; narrow palpebral fissure; albinism; congenital 
cataract; pigmentary retinitis. 

Anomalies of the ear. 

Anomalies of the limbs : Polydactyly ; syndactyly ; ectrodactyly ; sym- 
elus; phocomelus; excessive length of the arms. 

Anomalies of the trunk: Hernia?; malformation of the breasts and 
thorax ; dwarflshness ; giantism ; infantilism ; feminism ; masculinism ; 
spina bifida. 

Anomalies of the genital organs. 

Anomalies of the skin: Polysarcia; hypertrichosis; absence of hair; 
premature grayness. 

Physiological Stigmata. — Anomalies of motor function: Walking late; 
tics; tremors; nystagmus; epilepsy. 

Anomalies of sensory function : Deaf-mutism ; neuralgia ; migraine ; 
hyperesthesia ; anaesthesia; blindness; myopia; hypermetropia ; astig- 
matism; Daltonism; hemeralopia; concentric limitation of the visual 
field. 

Anomalies of speech : Mutism ; defective speech ; stuttering ; stam- 
mering. 

Anomalies of genito-urinary function : Enuresis ; sexual irritability ; 
impotence; sterility. 

Anomalies of the instinct or appetite : Merycism ; uncontrollable ap- 
petites for food, liquor, drugs, etc. 

Diminished^ resistance to external influences and diseases. 

Retardation of puberty. 

Psychical Stigmata. — Insanity; idiocy; imbecility; feeble-minded- 
ness; eccentricity; moral delinquency; sexual perversion. 

DEAF-MUTISM. 

Excluding the cases in which idiocy is present, which are not con- 
sidered in this chapter, deaf-mutism may be due either to congenital or 
acquired conditions ; the larger proportion of the cases belong in the lat- 
ter class. When congenital, deaf-mutism may result from ostitis, or 
periostitis of the temporal bone, encroaching upon the cavity of the 
middle ear, from ankylosis of the ossicles, from absence of the internal 
ear or any of its parts. There may also be colloid degeneration of the 
labyrinth. It may result from atrophy of the auditory nerve, and it 
may be due to a lesion of the brain. These congenital conditions are 



772 DISEASES OF THE NERVOUS SYSTEM. 

often hereditary. Acquired deaf-mutism is most frequently fche result 
of scarlet fever, and is due to otitis. The second important cause is 
cerebro-spinal meningitis, where it may be due to a lesion of the brain, 
the auditory nerve, or the ear. It occasionally follows mumps, diph- 
theria, measles, and other infectious diseases. It may result from re- 
peated attacks of acute otitis associated with adenoid growths or chronic 
rhino-pharyngitis. 

The younger the child at the time the deafness occurs the sooner the 
power of speech is lost. In most of the infectious diseases, if the attack 
occurs before the fifth year speech is lost. According to Love, total deaf- 
ness is rare among deaf-mutes; hearing for speech is present to a useful 
degree in about twenty- five per cent of the cases, while hearing by cranial 
conduction exists in nearly all cases. Deaf-mutism should be suspected 
if a child not idiotic shows at the end of two years no signs of beginning 
to talk. A careful distinction should be made between deaf-mutism 
and idiocy resulting either from congenital conditions or acquired dis- 
ease. 

It is necessary that this condition be recognised as early as possible, 
in order that the child may have the advantages of proper training 
during his early years. The physician should insist upon the child being 
sent as early as the third, and certainly by the fourth year to an institu- 
tion where it may be taught to speak. 

The treatment is mainly prophylactic. The most important relates 
to the care of the ears in scarlet fever, and the removal of adenoid vegeta- 
tions of the pharynx and other causes which produce attacks of acute or 
chronic otitis. For the condition itself education is the only thing to 
be considered. 



CHAPTER IV. 
DISEASES OF THE SPINAL CORD. 

MALFORMATIONS. 

Malformations of the cord are very frequently associated with those 
of the brain, and bear a certain degree of resemblance to them. (1) 
The cord may be absent (amyelia) ; this condition may exist alone or 
with absence of the brain. (2) The lack of development may be only 
partial (atelomyelia), as where some of the tracts are wanting. The 
most important one is defective development of the lateral tracts, which 
may be a cause of spastic paraplegia (Charcot). (3) There may be a 
malposition of some of the gray matter (heterotopia). (4) There may 
be a double cord (cliplomyelia) ; the division is generally incomplete, 
and is attributed to an abnormal development of the central canal; it is 



MALFORMATIONS OF THE SPINAL CORD. 773 

usually associated with other deformities. All of these malformations 
are extremely rare and of very little practical interest. 

There remains to be mentioned the only one which is really impor- 
tant — spina bifida. 

Spina Bifida.- — This is a malformation of the vertebral canal with a 
protrusion of some part of its contents in the form of a fluid tumour. 
The tumour is elastic, compressible, usually increased by crying, and 
sometimes by pressure upon the anterior fontanel. The contained fluid 
is clear serum, resembling in all respects the cerebro-spinal fluid. It is 
one of the most frequent congenital deformities. 

According to Humphrey, spina bifida is due to an early failure in 
development — in most cases before the cord is segmentated from the 
epiblastic layer from which it is developed. Hence it remains adherent 
to the epiblastic covering, and the structures which should be formed 
between the cord and the skin are undeveloped. For this reason there 
is in the wall of the sac a fusion of the elements of the cord, nerves, 
meninges, vertebral arches, muscles, and integument. If the error 
in development occurs later, the cord and nerves may be attached 
to the sac, but not intimately fused with it; in still other cases the 
cord does not enter the sac at all. The malformation may occur before 
the central canal is closed; or, if closed, it may reopen from the accu- 
mulation of fluid. It is probable that the accumulation of fluid first 
occurs, and that this prevents the union of the parts of the vertebral 
arches. 

Although the tumour is generally associated with a bifid spine, this 
is not necessarily the case. The protrusion may take place through the 
intervertebral notch or foramen, or there may be 
a fissure of the bodies of the vertebrae, and an an- 
terior tumour projecting into the cavity of the 
thorax, abdomen, or pelvis — spina bifida oc- 
culta. The principal anatomical varieties are 
meningocele, meningo-myelocele, and syringo- 
myelocele. 

Meningocele. — In this form there is a protru- 
sion of the membranes only (Fig. 148). The ac- f ig . 148. — Meningocele 
cumulation of fluid is either in the arachnoid cav- (partially diagrammatic). 

,. , n . , . ,, A, the membranes; B, 

ity or the subarachnoid space posterior to the the spinal cord; c the 
cord. The opening of communication between integument. The ac- 
the tumour and the spinal canal is small in this ^^cord!wMchdo^ 
variety, usually being about one-twelfth to one- not enter the sac. 
sixth of an inch in diameter. There may, how- 
ever, be no communication. The skin is usually fully developed (Fig. 
149 ) . The tumour is frequently globular, sometimes pedunculated, and 
may attain a very large size, being as much as five or six inches in diam- 




774 



DISEASES OF THE NERVOUS SYSTEM. 



eter. This is because spontaneous rupture is not likely to occur, and 
the tumour does not become infected except by operative interference. 

With such tumours patients may- 
live to adult life. This variety is 
most frequently seen in the cervi- 
cal region. It has the best chance 
of natural recovery, and in it op- 
eration stives the best results. 





Fig. 149. 



■Meningocele, in a Child One 
Year Old. 



Fig. 150. — Meningomyelocele (partially, 
diagrammatic). A, the membranes; B, 
the cord; C, the integument. The accu- 
. mulation of fluid is in front of the cord, 
the filaments of which are spread out, 
forming a part of the wall of the sac. 



lleningo-myelocele. — This is by far the most frequent variety of 
spina bifida, occurring in thirty-five of the fifty-seven cases reported by 
Demme. It is the form usually seen in the sacro-lumbar region. The 
accumulation of fluid takes place in the anterior subarachnoid space, 
less frequently in the anterior arachnoid cavity (Fig. 150). In this form 
the cord is contained in the sac, and usually forms a part of its wall. 
The tumour is smaller than the meningocele, the usual size being that 
of a mandarin orange. It is sessile, never pedunculated. As a rule it is 
only partly covered by skin, but has a central area, elliptical in shape, 
where there is only a thin, translucent membrane. This surface, which is 
known as the central cicatrix, is sometimes covered with granulations, 
and frequently ulcerates. The tumour often has a vertical furrow or 
a central umbilication. corresponding to the attachment of the cord 
on its inner surface. The usual relation of the parts is for the cord to 
run horizontally across the upper part of the tumour to the central 
cicatrix, with which it becomes blended, and from which again the nerves 
arise. These re-enter the canal at the lower part of the tumour, and are 
distributed below as usual. In other cases the cord joins the wall of the 
sac soon after its entrance, and its attenuated fibres are found spread out 
all over the sac, coming together again below and entering the spinal 
canal. 



MALFORMATIONS OF THE SPINAL CORD. 



775 



The following case, upon which I made an autopsy, is a good ex- 
ample of the common variety : The child died on the third day after birth 
from rupture of the sac. The tumour occupied the sacral region. The 
first sacral vertebra was normal, and beneath this the cord passed out of 
the spinal canal, terminating in the cauda equina soon after entering the 
sac, and continued back' to the central cicatrix. Here nerve filaments 
blended with the other tissues in an indefinite structure, from which 
again, with tolerable distinctness, the nerve structures could be seen to 
pass over the wall of the sac and return to the canal. The afferent and 
efferent nerves and the part of the membranes they carried with them 
formed several septa, making a smaller separate sac within the larger 
one. The large sac was clearly a dilatation of the anterior subarach- 
noid space, and communicated freely with the same space in the cord 
above. 

Syringo-myelocele. — In this variety the accumulation of fluid is in 
the central canal of the cord, the lining of the sac being here the at- 
tenuated and atrophied cord elements. This is the rarest form of 
tumour, but the one most frequently associated with hydrocephalus, and 
consequently having the worst prog- 
nosis. It may be found in the dorsal 
or dorso-lumbar region as well as in 
the lumbo-sacral (Fig. 151). 

With spina bifida other deformi- 
ties are frequently associated, the 
most common being club-foot, hy- 
drocephalus, more rarely encephalo- 
cele or cerebral meningocele, and 
hare-lip. If hydrocephalus exists, 
there is in most cases a dilatation of 
the central canal of the cord and 
a direct communication between the 
tumour and the lateral ventricles of 
the brain. Pressure upon the ante- 
rior fontanel causes an increase in 
the size of the tumour, and con- 
versely. Club-foot is usually dou- 
ble, most frequently talipes equino- 
varus. In a number of cases there 

is a history of some deformity in other members of the family. I once 
saw two successive children in the same family with spina bifida. 

Symptoms. — The tumour in spina bifida is present at birth, and is 
most frequently lumbo-sacral. Paralysis is frequent in myelocele and 
syringo-myelocele, but is not seen in meningocele; its degree and its 
location depend upon the situation of the tumour and the extent to 




Fig. 151. — Syringo-myelocele of the 
Mid-dorsal Region, in a Child 
Four Months Old, who also had 
Hydrocephalus. 



1 t 



6 



DISEASES OF THE NERVOUS SYSTEM. 



which the cord is involved. It is rare in cervical tumours, and most 
marked in those situated in the lumbo-sacral region. In the worst 
eases there is complete paraplegia, with paralysis of the bladder and 
rectum. If the tumour is sacro-lumbar or sacral, only the cauda equina 
is likely to be involved, and this but partially, so that the paralysis 
of the extremities is incomplete, and the bladder and rectum may 
escape. 

In Fig. 152 is shown a very remarkable case of sacral spina bifida 
in a boy of five years, who came under observation for incontinence of 

faeces. The tumour was a little 
more to the left than to the right 
side, and had been overlooked. It 
had evidently pressed upon the 
lower branches of the sacral plexus, 
so as to affect the sphincter and 
the gluteal muscles of the left side. 
The atrophy was very marked, as 
shown in the illustration. 

The natural course of spina bi- 
fida is to increase steadily in size; 
and if the tumour is covered by 
skin, its growth may be almost un- 
limited. It has been known to at- 
tain a circumference of twenty-two 
inches. If the integument is want- 
ing, and the sac wall is very thin, 
rupture is pretty certain to take 
place, either spontaneously or by 
some accident, in the course of the 
first few months; death then re- 
sults from convulsions owing to 
the rapid draining away of the cerebro-spinal fluid, or from second- 
ary infection. In a large number of cases death is due to marasmus 
dependent upon the associated conditions. Infection of the tumour 
may take place without rupture, the germs passing through the wall of 
the sac. If the opening communicating with the spinal canal is small, 
this infection may excite an inflammation limited to the wall of the 
sac, and result in a cure of the spina bifida, usually with sloughing. I 
have now under observation a girl ten years old in whom this occurred 
in infancy. The site of the former tumour is marked by a large dense 
cicatrix, and there still remains partial paralysis of the legs. If the open- 
ing into the spinal canal is large, inflammation of the sac is usually 
followed by spinal meningitis, which may extend upward and involve 
also the meninges of the brain. 




Fig. 152. — Sacral Spina Bifida. 



MALFORMATIONS OF THE SPINAL CORD. 777 

Prognosis. — This depends chiefly upon the anatomical variety and 
the existence of complications. Simple meningocele, when covered by 
integument, gives the best prognosis, and complete recovery may occur. 
In meningo-myelocele, especially if complete paralysis exists, the prog- 
nosis is bad; and if there is hydrocephalus, the case is hopeless. In 
quite a number of cases in which cure of the spina bifida has followed 
operation, hydrocephalus has subsequently developed. Of fifty-seven 
cases rej^orted by Demme, twenty-five were operated upon, with seven 
recoveries and fifteen deaths, while three were unimproved ; of the thirty- 
two cases not operated upon, twenty-eight died within the first month, 
and not one lived over two years — the causes of death being marasmus, 
rupture of the sac, and meningitis. 

Diagnosis. — It is usually easy to recognise spina bifida, but it is often 
difficult to distinguish between the different varieties. The absence of 
a palpable fissure in the spine, perfect translucency, and a pedunculated 
tumour, all point strongly to meningocele. Paralysis of the sphincters 
and lower extremities, umbilication of the centre of the tumour, a sessile 
tumour, a palpable bony fissure, and a large central cicatrix, point to 
meningo-myelocele. The coexistence of hydrocephalus points to syringo- 
myelocele. 

Treatment. — In all cases the tumour should be protected from pres- 
sure, and care taken where it is not covered by integument, that the sur- 
face is kept absolutely clean and aseptic. It should be covered with 
some antiseptic powder and surrounded by a large pad of absorbent cot- 
ton, or a rubber ring-cushion. Complete paraplegia with involvement of 
the bladder and rectum, hydrocephalus, or extreme marasmus — all con- 
traindicate operative interference. If these are absent, operation should 
be considered. The time of operation will depend somewhat upon the 
nature of the tumour. If it is covered by integument and growing 
slowly, it is well to wait until the child is at least six months old. In 
other cases delay is dangerous, because of the liability to spontaneous or 
accidental rupture. 

The treatment by injection has now been entirely superseded by the 
operation of excision of the sac. For a description of this and the 
various plastic operations that have been proposed in connection with 
it the reader is referred to works upon operative surgery. In operating, 
it should not be forgotten that in the great proportion of the cases (nine- 
ty-five per cent, according to the London Clinical Society's Report, 
which, however, refers only to fatal cases) some part of the cord is in 
the sac. The cord is often present in tumours situated below the third 
lumbar vertebra, owing to its attachment to the sac. 

Although recovery may follow operation, in a very large number of 
cases it is incomplete; some degree of paralysis, with atrophy, contrac- 
tures, and deformities, remaining because of the implication of cord ele- 



778 DISEASES OF THE NERVOUS SYSTEM. 

ments in the sac. In a considerable proportion of eases, hydrocephalus 
subsequently develops, as after similar operations upon cerebral menin- 
gocele. 

SPINAL MENINGITIS. 

In acute meningitis usually only the pia mater is involved. This 
rarely occurs alone, unless it is due to traumatism. It is most frequently 
associated with inflammation of the pia of the brain, and may occur 
either with the meningococcus or the tuberculous variety. A certain 
amount of acute inflammation of the pia mater accompanies most of the 
cases of acute myelitis. 

Chronic spinal meningitis in children usually involves the dura only. 
Inflammation of the external layer (external pachymeningitis) is usually 
secondary to caries of the vertebra?. This is considered in the article on 
Compression-Myelitis. 

Symptoms. — The symptoms of inflammation of the spinal membranes, 
no matter with what pathological condition it may be associated, are due 
to irritation of, or pressure upon, the cord or nerve roots. Those which 
are most common are : pain in the back, which is increased by move- 
ment, and usually by pressure upon the spinous processes; radiating 
pains following the course of the spinal nerves, felt in the extremities or 
in the trunk; rigidity of the spinal column due to spasm of the spinal 
muscles, or rigidity of the muscles of the extremities ; and hyperesthesia 
along the spine, which may be quite acute. When pressure upon the 
cord is added, there is paralysis or paresis, sometimes muscular atrophy 
and anaesthesia. Any of the above symptoms may be acute or chronic, 
according to the nature of the primary disease. 

The diagnosis between spinal meningitis and myelitis is often not 
easy, for except in acute cases the two processes are usually associated; 
and in a given case it may be difficult to decide whether the lesion of the 
cord or of the membranes is the more important one. In meningitis, 
pain, tenderness, spasm, and irritative symptoms are generally more 
prominent, while loss of power and anaesthesia are usually partial. In 
myelitis the pain, tenderness, and other irritative symptoms are less 
marked, while paralysis and anaesthesia may be complete. 

Treatment. — This relates first to the disease with which it is asso- 
ciated; in addition, counter-irritation by means of thePaquelin cautery, 
rest in bed, and in severe cases even immobilisation of the spine by a 
mechanical support. Iodide of potassium is often useful. 



MYELITIS. 

Myelitis is a rare disease in children, with the exception of two vari- 
eties which are discussed under separate heads, viz., compression-myelitis 



MYELITIS. 779 

and acute poliomyelitis. Otherwise myelitis usually results from injury, 
but it may occur as a complication of any of the acute infectious dis- 
eases, especially typhoid or scarlet fever, and diphtheria, and even as 
a primary disease, when it is attributed to exposure or cold, but when 
it is probably infectious. Chronic myelitis may be due to hereditary 
syphilis. 

Myelitis usually occurs in children over ten years of age. In situa- 
tion, it may be transverse, diffuse, or disseminated; the process may be 
acute, subacute, or chronic. The lesions and the symptoms are essen- 
tially the same as when the disease occurs in the adult. 

Symptoms. — Myelitis usually comes on rather gradually, with only 
local symptoms; but the onset may be quite acute, with severe general 
symptoms — fever, pain, prostration, and localised or general convul- 
sions. The local symptoms vary with the seat and the extent of the 
disease. 

In transverse myelitis loss of power and anaesthesia are present below 
the level of the lesion ; either of these may be partial or complete. At the 
level of the lesion there is a zone of hyperaesthesia and " girdle-pains." 
All the reflexes below the seat of the lesion are exaggerated. Those 
at the level of the lesion are lost. There may be loss of control 
of the sphincters, bed-sores, degenerative changes in the paralysed 
muscles, contractures, and vaso-motor disturbances. The paralysed mus- 
cles may be rigid or flaccid, according to the seat and extent of the 
lesion. 

When transverse myelitis is situated in the cervical region there are 
paralysis and anaesthesia of the arms, legs, and trunk. All the reflexes 
are exaggerated, and there is general rigidity of the paralysed muscles. 
There are incontinence of faeces and retention of urine, followed by in- 
continence from overflow. The pupils are frequently contracted, and 
there may be optic neuritis. Atrophy, when present, usually affects the 
muscles of the arms, and indicates that the cord to a considerable extent 
is involved. There is great danger to life, owing to paralysis of the 
muscles of respiration. 

When the seat of disease is the dorsal region, the symptoms are simi- 
lar to those above described, with the exception that the arms escape, 
and that the eye-symptoms are usually wanting. This is the most fa- 
vourable seat of the disease. 

When the disease is situated in the lumbar region, in addition to 
paraplegia and anaesthesia of the legs, there is, from the beginning, in- 
continence of urine and faeces. The knee reflexes are lost; the muscles 
atrophy, and usually give the reaction of degeneration. Bed-sores are 
frequent. 

In diffuse myelitis the symptoms are a combination of the above 
groups. If a large part of the cord is involved, there are general paral- 



7S0 DISEASES OF THE NERVOUS SYSTEM. 

ysis and anesthesia, loss of reflexes, marked trophic disturbances, bed- 
sores, etc. 

The course of myelitis is slow, and it usually progresses steadily from 
bad to worse. Death is due to exhaustion or complications — cystitis, bed- 
sores, or hypostatic pneumonia — or to some intercurrent disease. In a 
small proportion of the cases there may be partial recovery, but very 
rarely is this complete. The diagnosis is to be made from spinal menin- 
gitis, tumours, and haemorrhage. 

Treatment. — The treatment of the early stage consists in the use of 
ice to the spine, or counter-irritation by means of dry cups, mustard, or 
the Paquelin cautery. Later, the iodide of potassium should be given in 
all cases; improvement may follow its use, even when there is no suspi- 
cion of s} r philis, but large doses are required, and for a long period. 
Electricity is contraindicated except in chronic cases, and then but little 
improvement is likely to result from its use. In these patients the most 
important thing is careful attention to cleanliness and to posture, in 
order to prevent bed-sores, cystitis, and pneumonia. 

COMPRESSION-MYELITIS 

(Pressure-paralysis of the Spinal Cord; Pott's Paraplegia.) 

Compression-myelitis is sometimes traumatic, but usually follows 
caries of the spine. It most frequently complicates this disease when the 
cervical or upper dorsal vertebrae are involved, rarely when the lower half 
of the spinal column is affected. This difference is probably due to the 
smaller size of the spinal canal in its upper portion. According to Gib- 
ney, paraplegia is seen in fifty per cent of the cases of caries of the upper 
half of the spine. Essentially the same condition, so far as the cord is 
concerned, may result from tumours of the spinal cord, or from anything 
else causing pachymeningitis. These, however, are exceedingly rare in 
childhood. 

Lesions. — In spinal caries there occurs as a result of tuberculous dis- 
ease a softening of .the bodies of the vertebrae, which fall together from 
the pressure due to the superincumbent weight of the body. This causes 
a backward projection known as the kyphosis, or angular deformity. The 
spinal canal is encroached upon by the remains of the vertebral bodies 
whose ligamentous attachments have been loosened, and also by inflam- 
matory products the result of periostitis, and localised inflammation of 
the dura mater, chiefly of the external layer, but which sometimes affects 
the internal layer also. All these conditions lead to the production of a 
mass of inflammatory material, often containing tuberculous deposits, 
which is chiefly in front of the cord, but may surround it. The compres- 
sion takes place slowly in most of the cases, from the gradual progress of 
the lesions mentioned. In a small number of cases there may be a 



COMPRESSION-MYELITIS. 78 1 

sudden pressure from the slipping backward of one of the vertebral 
bodies. 

In recent cases the cord at the seat of compression is a little smaller 
than normal. It is usually involved to the extent of from half an inch 
to two inches. Paraplegia may have existed when the changes found in 
the cord are very slight, and sometimes when no changes are visible to 
the naked eye. In more protracted and more severe cases, the cord is 
much smaller at the point of disease, and under the microscope shows 
the changes of interstitial myelitis (Gowers) with meningitis. In old 
cases there are degeneration of the nerve elements, atrophy, and sometimes 
disappearance of the ganglion cells, with more or less destruction of the 
nerve fibres; sometimes all distinction between the gray and white sub- 
stance is lost. In addition to these marked changes at the point of pres- 
sure, there may be ascending or descending degeneration, as from other 
focal lesions. There is usually inflammation of the nerve roots, which 
have also suffered compression. It is in many cases surprising to 
see to what degree the cord may be compressed and still preserve its 
functions. 

Symptoms. — In caries of the cervical region the symptoms of com- 
pression-myelitis not infrequently precede the deformity, and, in fact, the 
other objective symptoms of bone disease. The earliest symptoms of 
caries usually arise from irritation of the nerve roots, and consist of 
acute pains not often referred to the spine, but radiating to the different 
regions to which these nerves are distributed. They are felt in the neck, 
in the chest, in the epigastrium, and sometimes in the loins. Accom- 
panying these pains, there is noticed a gradual weakness in the lower 
extremities, and sometimes also in the arms, according to the location 
of the disease. This may steadily increase for several weeks until there 
is complete paralysis. Other symptoms are then commonly present. 
There is usually some degree of anaesthesia, and there may be numbness, 
tingling, formication, and pain. The sphincters are not often involved. 
When the disease is in the upper half of the cord, there are rigidity of the 
extremities and great exaggeration of all the reflexes, with marked ankle- 
clonus. In the rare cases in which the lumbar enlargement is involved, 
there may be loss of reflexes, paralysis of the sphincters, and bed-sores. 

The distribution of the paralysis will depend upon the point of com- 
pression. If this is in the cervical region, all four extremities will be 
paralysed ; if in the dorsal region, only the legs. According to the extent 
of the secondary lesions in the cord, there may occur muscular atrophy 
and contractures. With disease in the upper cervical region, death may 
result from sudden pressure upon the cord, owing to a dislocation of the 
odontoid process; or there may be vomiting, pupillary symptoms, irri- 
tation of the phrenic nerve causing hiccough, or pressure causing paral- 
ysis of the diaphragm. 



782 DISEASES OF THE NERVOUS SYSTEM. 

Course and Prognosis. — These depend much upon the treatment of 
the ease. In many cases of paralysis occurring early in caries, complete 
recovery takes place in the course of a few weeks, sometimes in a few 
days, after the application of a proper mechanical support. In the cases 
which have been long neglected, or those in which the paralysis develops 
while proper mechanical treatment is being carried out, the chances are 
not so good. Gibney gives the following statistics of 133 cases under his 
personal observation: 31 proved fatal; 9 dying from myelitis, 14 from 
other diseases subsequent to recovery from the paralysis, and 6 from tu- 
berculosis before complete recovery; 74 recovered from the paraplegia; 
27 were recorded as improved or still under treatment. Relapses oc- 
curred in about fifteen per cent of the cases. The usual duration of the 
disease is from three months to two years. Recovery has often taken 
place in cases that have persisted for four or five years. 

Diagnosis. — This is rarely difficult. Spinal caries should be suspected 
in every case when the symptoms point to transverse myelitis coming 
on without definite cause. 

Treatment. — The indications are the removal of pressure and the 
fixation of the spine by a proper mechanical support. Other measures 
to be advised are the Paquelin cautery and the internal use of potassium 
iodide. From his very extensive experience, Gibney has more confidence 
in this drug than in all else except mechanical treatment. Large doses 
are required, often from sixty to ninety grains being given daily for 
months. The iodide should always be largely diluted. Patients should 
be kept scrupulously clean, and the position changed frequently to pre- 
vent the formation of bed-sores. Electricity is contraindicated. When 
the paralysis develops rapidly or occurs suddenly, relief may sometimes 
be obtained by the operation of laminectomy ; but little is to be expected 
from this in the slow cases. 

ACUTE POLIOMYELITIS. 

(Epidemic Poliomyelitis; Acute Infantile Paralysis.) 

There are few diseases regarding which our knowledge has increased 
so rapidly during recent }^ears as acute poliomyelitis. The first great 
step in advance was made by Landsteiner and Popper, who, in the sum- 
mer of 1909, succeeded in producing the disease in a monkey by intra- 
peritoneal inoculation with the spinal cord of a patient dying of acute 
polionvyelitis. They were not successful in carrying the transmission 
further. But shortly after this Flexner and Lewis, using the intra- 
cranial method of inoculation, had no difficulty in reproducing the dis- 
ease and transmitting it through an indefinite series of monkeys. Xo 
other animals seem to be susceptible. These observations, now many 
times repeated, have not only definitely established the infectious char- 



ACUTE POLIOMYELITIS. 783 

acter of poliomyelitis, but have cleared up many doubtful points in its 
pathology. 

Acute poliomyelitis is now regarded as a communicable, infectious 
disease which prevails both epidemically and sporadically. Although 
possibly its most characteristic lesions are in the anterior horns of the 
cord, any part of the central nervous system may be affected. The 
changes in the cord substance are preceded by lesions of the meninges. 
Although the name poliomyelitis is still retained, the scope of the term 
has been greatly widened. 

This disease is characterised by an acute onset, with fever and usu- 
ally other marked constitutional and nervous symptoms, from which 
there may be rapid recovery; but generally there follows early and ex- 
tensive loss of power. After this there is usually seen a gradual im- 
provement, and sometimes complete recovery. More often, however, 
there is left some permanent paralysis in certain groups of muscles, 
which undergo rapid and marked atrophy. Formerly, poliomyelitis was 
seen chiefly as a sporadic disease ; but since the year 1905 epidemics have 
occurred with increasing frequency in various parts of the world, and 
especially in the United States since 1907. As it is most frequently 
seen in very young children, and as it is altogether the most common 
form of paralysis at this period, the old term of " acute infantile paral- 
ysis " is perhaps the most appropriate clinical designation. 

Etiology. — Fully eighty per cent of the cases are seen in the first 
three years of life, the greatest incidence being in the second year. Per- 
sons of any age may be attacked, and in some epidemics the proportion 
of adult cases is quite large. Epidemics thus far observed have invariably 
occurred in the warm months ; those in the United States, from July to 
October. Fully four-fifths of the sporadic cases also are seen during 
these same months. 

Bartlett and myself 1 could find recorded, previous to 1905, but 34 
epidemics or outbreaks of this disease. Most of these were small in ex- 
tent, and the total number of cases reported in all was only 889. 

The prevalence of poliomyelitis in an epidemic form really begins 
with the outbreaks in Sweden and Norway in 1905 and 1906. These 
were follow^ in 1907 by the epidemic occurring in New York City and 
vicinity which was the most extensive yet known; there were observed 
from July to October between 2,000 and 3,000 cases. Since that time 
poliomyelitis has been gradually spreading to nearly all parts of the 
United States and in its progress has distinctly followed lines of travel. 
It has been especially prevalent in Massachusetts and Rhode Island; 
in Minnesota, Wisconsin and Iowa, and in Pennsylvania. In the year 

1 See American Journal of the Medical Sciences, May, 1908. Also Archives of 
Paediatrics, September, 1910. 



7sl 



DISEASES OF THE NERVOUS SYSTEM. 



1910 Dearly ^,000 cases were reported in the United States While the 
greatest Dumber of outbreaks of this disease have been seen in this 
country, some of considerable size have occurred in Australia and in 
Germany. The same locality has rarely been the seat of an epidemic in 
two successive seasons. 

The instances recorded, now numerous, of the occurrence of several 
successive eases in a family, strongly suggest that the disease is directly 



6 /28 

Vl5 

v 25 




1V2 V5 VlO y /l9] B 

1V3 V6 VlQVu\ C 

1V4 y /22l P 

1V4 VlO Vl6 7 /l7 y /23l E 

7 /8 7 /20 7 /21 7 /27 7 /28lF 



/ | 7 /22 7 /24 8 /4 | H 

| 7 /10 7 /l8l G — 1 V29 H 

y /23 U 



y 12 y /l6 y /20"V22l K 
V15 y /23 V24lL 



V20M 



l 7 /20 7 /24 r /27| R \W l 7 /lo 7 /l9 rV20| i\ 



luteins \\ Vt |yulo 

V/18 V23I Q 

Fig. 153. — Trostena Epidemic of Poliomyelitis. (After Wickman.) The epidemic 
was observed in a rural community of 500 persons in which 49 cases occurred in six 
weeks. The letters, A, B, C, etc., represent the different families in which cases 
occurred. The figures give month and day of onset of each case. Heavy figures 
indicate cases with paralysis; lighter figures, abortive cases. The relation of the 
families to the school is indicated by lines; in those connected by solid lines the chil- 
dren who attended school were first attacked; in those connected by dotted fines, 
some child attended the school, but the school child was not the first one attacked. 
The first case occurred in Family A, the child attending school while suffering from 
the early symptoms of the disease. In only two families (R and S) did cases occur 
in which there was no association with the school or with families whose children went 
to school. 



communicable. In some epidemics, notably those of York Xebraska, 
and Trostena, Sweden (see Fig. 153), the evidence of contagion would 
seem to be almost conclusive. There are also instances in which the dis- 
ease apparently was carried by a third person. 

it is at present difficult to reconcile the facts indicating a high degree 
of eommunicability, such as has been witnessed in some epidemics, with 
what has been observed at other times and in other places. In many of 
the epidemics, when the disease has prevailed extensively, it has not been 
possible to trace any connection between the different cases. In the 



ACUTE POLIOMYELITIS. 785 

majority of the families but one case occurred, although other children, 
quite as susceptible hv reason of age, were closely exposed. For years 
we have received these affected children in the acute stage into hospital 
wards with other patients, and 1 have never yet known a secondary case 
to develop. Until recently, no effort whatever was made to isolate cases. 
At present we are able to recognise no differences between the sporadic 
and epidemic forms of the disease except in communicability and se- 
verity, which point to a greater virulence of the infection in the latter 
variety. Both etiologically and pathologically, the sporadic and epidemic 
forms seem to be identical. In all these respects the analogy to cerebro- 
spinal meningitis is a very close one. 

The occurrence during epidemics of many unrelated cases strongly 
suggests some other mode of contracting the disease than directly from 
an infected person or a human carrier. The fact that epidemics are 
seen only during the summer and early autumn points in the same direc- 
tion. Eecent experiments of Flexner and Clark give some reasons for 
suspecting the house fly as a carrier. The question remains to be solved 
by future investigation. 

The period of incubation of the experimental disease in monkeys 
varies from four to thirty-three days, the average being ten days. In 
man, also, it is variable, but in most instances the second case in a family 
has followed the first one within ten days. 

The Specific Virus. — It belongs to the class of filtrable viruses, closely 
resembling, in many respects, the virus of rabies. It passes through the 
finest porcelain filter. It can not be seen with the highest power of the 
microscope, nor has it yet been cultivated outside the body. That it is a 
living organism is proven by the fact that it is destroyed by heat. It is 
present in largest quantity in the diseased nerve structures, particularly 
the spinal cord. In the earliest stages of the attack it is also found in the 
cerebro-spinal fluid, but disappears at about the time paralysis occurs. 
It exists to some degree in other tissues of the body, particularly the 
lymph nodes. The disease can be transmitted to animals regularly and 
with certainty only by inoculation with an affected spinal cord, in which 
the virus persists for months after the acute attack. Experiments indi- 
cate that the path of entrance may be the nasal mucous membrane, and at 
times the intestinal tract. Osgood and Lucas have shown that the virus 
persisted in the nasal mucous membrane of monkeys, in one instance for 
five months, in another for one and a half months, after the acute attack ; 
which suggests that this may not only be an avenue of entrance, but a 
mode of elimination of the infection, and indicates that the duration of 
the infective period may at times be a very long one. 

Lesions. — As a result of the investigations, particularly of Flexner 
and Lewis upon animals, and those of Harbitz and Scheel, Strauss, and 
others upon the disease in man, the pathology of acute poliomyelitis is 
51 



786 DISEASES OF THE NERVOUS SYSTEM. 

now well known. This knowledge has greatly aided our clinical under- 
standing of the disease. 

The virus of acute poliomyelitis first attacks the meninges, especially 
of the cord and medulla, setting up a cellular inflammation of the pia, 
which becomes infiltrated with small, round cells. These changes are 
most marked about the hlood- vessels. Besides this the walls of the ves- 
sels themselves are infiltrated and their lumen narrowed. The lesion 
also affects the vessels entering the nerve structures. As a result of the 
vascular lesions anaemia, oedema, and haemorrhages are present, some- 
times small and circumscribed, sometimes quite diffuse and extensive. 
Thrombosis does not occur. But more important still are the degener- 
ative changes in the nerve cells, the site and extent of which are deter- 
mined by the vessels involved and the intensity of the changes in them. 
The lesions in the pons, medulla, and cerebrum, like those in the cord, 
are secondary to the vascular lesions. 

The transient paralysis in cases that recover may be due to oedema or 
to temporary vascular obstruction from pressure outside the vessels 
causing a local anaemia. Permanent paralysis depends upon severe de- 
generation and actual destruction of ganglion cells; its extent, there- 
fore, will vary with the number of the ganglion cells affected. Any part 
of the central nervous system may be affected, and the lesions are gen- 
erally more extensive than the symptoms would lead one to expect. The 
gross appearances give but little idea of their severity. The process 
often involves nearly the whole length of the cord, being, however, gen- 
erally most marked in the cervical and lumbar enlargements. The 
changes are chiefly in the gray matter of the anterior horns, and consist 
in acute degeneration of ganglion cells, usually marked and extensive. 
These cells in certain parts may disappear altogether, being replaced by 
leucocytes. The entire cord, however, may be involved. There is seen, 
but to a much less degree, infiltration with small round cells of the pos- 
terior horns, the columns of Clarke, and the white matter of the cord, 
everywhere closely related to the blood-vessels. There are regularly 
found changes in the spinal ganglia of a similar character to those 
described in the cord. 

Lesions like those of the cord, though generally less marked, are 
seen in the pons, the medulla, the cerebellum, and even in the cerebral 
hemispheres. They are, as in the cord, especially related to the pia and 
the blood-vessels. There is seen acute destruction of ganglion cells 
and areas of cell infiltration with lymphocytes. The changes are espe- 
cially marked about the nuclei of the cranial nerves, and in the gray 
matter about the fourth ventricle. In some cases the basal ganglia 
are also involved. Areas of infiltration, sometimes quite diffuse, may 
he seen in the cortex, with also some slight degeneration of ganglion 
cells. 



ACUTE POLIOMYELITIS. 787 

Thus, in the severe and fatal eases there is present a diffuse inflam- 
mation of the entire cord and its membranes, also of the medulla, pons, 
and basal ganglia, with less marked changes in the cerebrum, always 
accompanied by changes in the pia. In the milder cases it is probable 
that the inflammatory changes are limited to the cord, though in some 
patients dying later from other causes Harbitz and Scheel discovered 
changes in the upper centres, though no symptoms pointing to them 
had been present. From this account of the lesions it would appear 
that we can no longer distinguish between the lesions of acute polio- 
myelitis, acute bulbar paralysis and acute poliencephalitis inferior. They 
represent varying phases of one and the same disease. In recent acute 
cases no changes are usually found in the nerves except degeneration of 
bundles, corresponding to the degenerated areas in the cord, and prob- 
ably secondary to them. Lesions in other organs are often present, the 
most frequent being broncho-pneumonia and acute parenchymatous de- 
generation of the liver and kidneys, similar to what is seen in other 
severe general infections. The thymus, the solitary follicles of the in- 
testine, and the mesenteric glands may be much swollen. 

In autopsies made upon cases of long standing the affected part of 
the cord, which is often only one lateral half, is smaller than normal. 
The general changes are those of a sclerotic character. The ganglion 
cells of the affected anterior horn have either disappeared altogether, or 
they are few in number and so shrunken as to be hardly recognisable. 
The white matter also is smaller than in the sound part of the cord. 
The anterior nerve roots are degenerated quite to the muscles. The 
affected muscles are atrophied, and in extreme cases there may be a 
complete disappearance of muscle fibres, their place being taken by adi- 
pose and fibrous tissue. In places where the lesion is less severe the 
fibres are small. The affected limb is shorter and the bones smaller 
than upon the sound side. 

Symptoms. — The onset of a well marked attack of acute poliomyelitis 
is usually abrupt, being ushered in with fever, prostration, vomiting, 
rarely with convulsions. There may be diarrhoea, but more often there 
is obstinate constipation, and there may be retention of urine. Severe 
pains are usually present in the neck, the spine, and the extremities. 
There may be marked hyperesthesia with so much rigidity of the neck 
and extremities as strongly to suggest cerebro-spinal meningitis. The 
mind is usually clear, but there may be active delirium or, rarely, 
drowsiness or stupor. The temperature usually ranges between 102° 
and 103.5° F. Such symptoms may continue for three or four days 
and then gradually subside and the patient recover without any paralysis 
having developed. Or there may be for a few days a general muscular 
weakness somewhat greater and lasting a little longer than would be 
expected in an illness of such severity. These are known as " abortive 



788 DISEASES OF THE NERVOUS SYSTEM. 

cases." In most of them the constitutional and nervous symptoms are 
similar, but not quite so severe as those just described. How frequent 
the abortive type of the disease occurs it is impossible to say; but in 
epidemics these cases are not uncommon and doubtless may equal the 
number of the paralytic cases. Except when associated with the latter 
they are very difficult of recognition. 

Instead of following such a course as that described there develops, 
usually on the third or fourth day of the attack, marked muscular weak- 
ness most frequently in the lower extremities. This increases for three 
or four days until there may be complete paralysis, which may affect 
one or both lower, or all four extremities, or only the upper ones. There 
may also be marked weakness or even true paralysis of the neck and 
trunk. But there is no anaesthesia. The fever and other constitutional 
symptoms rarely last more than six or seven days, and often but three 
or four. The early symptoms are not characteristic, and a positive diag- 
nosis before the occurrence of paralysis is seldom made. The extent of 
the primary paralysis is generally in proportion to the severity of the 
constitutional symptoms. 

Instead of such marked constitutional and local symptoms, even in 
epidemics many milder attacks are seen, and when the disease occurs 
sporadically most of the cases are of the milder type. There is usually 
a period of indefinite indisposition lasting one or two days, at the end 
of which time the paralysis is noticed. Sometimes there is only a single 
restless night, following which the paralysis is seen in the morning. In 
two cases of which I have notes the paralysis apparently came on while 
the child was walking in the street, and was able to reach home only with 
considerable difficulty, there having been no previous symptoms ob- 
served. In cases of this type the loss of power is usually limited to 
one limb, often to a single group of muscles. 

In the types just described the symptoms are chiefly due to the spinal 
cord lesion. In others, however, involvement of the cranial nerves in- 
dicates a bulbar lesion. Cases of this type are seldom seen except in 
epidemics, when their occurrence is not uncommon. In this form the 
early symptoms may be like those just described or there may be con- 
vulsions followed by delirium or stupor. The early paralysis may in- 
volve the extremities only, but soon the muscles of the trunk and neck 
become affected. There may then develop paralysis of the face, marked 
disturbance of the respiration or of the action of the heart, and some- 
times difficulty in deglutition. The bladder and rectum may be in- 
volved, causing retention of urine and incontinence of faeces. Death may 
take place quite suddenly by failure of the heart or respiration usually 
from the fourth to seventh day, or at a later period death may be due 
to broncho-pneumonia. Cases of this kind, when they occur sporadic- 
ally, are often miscalled Landry's paralysis. 



ACUTE POLIOMYELITIS. 



789 



Extent and Distribution of the Primary Paralysis. — In 560 sporadic 
cases in which this point was noted the distribution was as follows : 

One lower extremity 229 cases. 

Both lower extremities 176 " 

General paralysis of all extremities, and more or less of trunk. 79 " 

One lower and one upper extremity 36 " 

Both lower extremities and on; 1 upper extremity 16 " 

One upper extremity alone 14 " 

All other varieties 10 " 



In paralysis of the trunk, the abdominal muscles, the diaphragm, and 
other respiratory muscles are rarely affected. In combinations of an upper 
and a lower extremity, the limbs are more frequently affected upon oppo- 
site sides than upon the same side. The sphincters usually escape. 

Course of the Disease. — After the constitutional symptoms have dis- 
appeared there is a period of from one to three weeks' duration in which 
little change is seen. This is followed by spontaneous improvement, 
which usually begins in 
the muscles last affected, 
and reaches its limit in 
about three months. The 
paralysis remaining after 
this time is likely to be 
permanent. By the end 
of six or eight weeks 
atrophy is present in the 
paralysed muscles. The 
affected limb is distinctly 
smaller than its fellow, 
this being quite appar- 
ent even in infants. Ex- 
cept in the early stage, 
sensory disturbances are 
absent; the knee-jerk is 
lost in paraplegic cases. 
and in those in which the 
extensors of the thigh are 
paralysed. There is ar- 
rested growth in the whole 
limb (Fig. 154). It be- 
comes much smaller and 

shorter than its fellow. The great relaxation of the ligaments at the 
joints may allow subluxation, especially at the knee and at the shoulder. 
The circulation in the affected limb is poor; it is often blue and cold, 
but bed-sores are never seen. 




Fig. 154. — An Old Case of Infantile Spinal Paraly- 
sis of the Entire Left Lower Extremity. 
Showing extreme atrophy of the thigh and leg, and 
a very characteristic deformity of the foot. 



790 



DISEASES OF THE NERVOUS SYSTEM. 



Electrical Reactions. — Very early in the disease the atrophied mus- 
cles begin to lose their power to respond to faradism. In the muscular 
groups which are to be permanently paralysed, the faradic response may 
be lost in a week. The muscles in which recovery is to take place often 
preserve a certain degree of contractility, although this is less than 
normal, and improves later. The response to the galvanic current may 
be increased for a few months, and then slowly fail as the muscular 
fibres themselves degenerate, and at the end of two or three years it may 
disappear altogether. The reaction of degeneration is present with great 
uniformity in the atrophied muscles, but in them alone. 

Residual Paralysis and Deformity. — This is most frequently of one 
lower extremity. The extensors both of the thigh and of the leg are 
nearly always involved to a greater degree than the flexors. The muscles 

most frequently affected are the anterior 
tibial group. Paralysis of one upper ex- 
tremity rarely occurs alone, but is asso- 
ciated with paralysis of one or both lower 
extremities. Complete paralysis of an 
arm is very rare. Of single muscles, the 
one most frequently involved is the del- 
toid. From paralysis of the muscles of 
the trunk or shoulder of one side, lateral 
curvature may develop (Fig. 155). 

Diagnosis. — The recognition of acute 
polion^elitis before the occurrence of 
paralysis is impossible except by lumbar 
puncture. If this is performed early, the 
cerebro-spinal fluid is found to be opal- 
escent or slightly turbid, owing to the 
presence of many mononuclear cells. It 
may coagulate spontaneously. J^oguchi's 
globulin test gives a positive reaction. 
By the time paralysis appears the cells 
have diminished greatly in number 
and soon the fluid shows no changes by which it can be distinguished 
from the normal. Very exceptionally there has been seen early in the 
disease a marked turbidity and an excess of polymorphonuclear cells. 
Such cases are distinguished from meningitis by the absence of the char- 
acteristic organisms. The early symptoms — vomiting, constipation, or 
diarrhoea and fever — usually lead to the opinion that this attack is only 
one of acute indigestion. When there are added muscular pains, general 
hyperesthesia, rigidity, and high fever, cerebro-spinal meningitis is often 
suspected, and can be excluded only by lumbar puncture. Early cerebral 
symptoms, convulsions, stupor, etc., may closely simulate tuberculous 




Fig. 155. — An Old Case op In- 
fantile Spinal Paralysis of 
the Left Arm and Shoulder 
Muscles, with Resulting Lat- 
eral Curvature. 



ACUTE POLIOMYELITIS. 791 

meningitis, and I have known doubt to exist for several da} r s. Lumbar 
puncture and the examination of the fluid should settle the diagnosis. 

The later manifestations of poliomyelitis are a flaccid type of paralysis 
with marked atrophy and with the characteristic electrical reactions, but 
without sensory symptoms. Seen late, poliomyelitis may be confounded 
with cerebral palsies, multiple neuritis, or the pseudo-paralysis of rickets. 
In cerebral palsies there is usually rigidity; there is no reaction of 
degeneration; other cerebral symptoms are commonly present, or there 
is a history of an onset with cerebral symptoms, and the atrophy is 
less marked. Multiple neuritis is rare in children except after diph- 
theria, and is more gradual in its onset. The type of paralysis and the 
electrical reactions may be the same as in poliomyelitis. 

Certain birth palsies, especially those resulting from injuries received 
during deliver}^ may closely resemble poliomyelitis when the deltoid or 
shoulder group of muscles is involved. Without a clear history a differ- 
ential diagnosis may be impossible. 

The muscular weakness of rickets is general; there is no reaction 
of degeneration and no history of acute onset. Scurvy is distinguished 
by the very acute hyperesthesia, by the swellings, and by haemorrhages 
from the gums or other mucous membranes together with a history of im- 
proper feeding. The child refuses to move his legs only because of pain. 

Prognosis. — It was once thought that few, if any, cases recovered 
perfectly, and on the other hand that there was very little danger to 
life. Wider observations which recent epidemics have made possible 
have shown that complete recovery may occur even in cases in which 
the onset is acute and early loss of power extensive. Such a result is, 
however, not the common one. The great majority of the cases have 
unfortunately some residual paralysis. Of the 1,659 cases occurring in 
epidemics collected by Bartlett and myself the mortality was twelve 
per cent. During the recent New York epidemic I saw personally four 
cases which ended fatally. The discrepancy between the mortality figures 
just mentioned and the opinion formerly held is possibly explained in 
part by the fact that in epidemics the more severe types of the disease 
are seen, but I believe is chiefly due to a failure to recognise the most 
severe forms, especially bulbar cases, as examples of this disease. Pre- 
vious statistics have been gathered chiefly from neurological out-patient 
clinics, where the types which end fatally are seldom seen. 

An important question in early prognosis is that which relates to 
the extent of the permanent paralysis. The significant symptoms are 
the amount of wasting and the electrical reactions. Muscles which in 
ten days have lost completely their faradic contractility are almost cer- 
tain to waste rapidly and severely. The best indication of coming im- 
provement is the return of faradic contractility. If this is completely 
lost for six months, recovery is doubtful; if for one year, improvement 



792 DISEASES OF THE NERVOUS SYSTEM. 

in those muscles is not to be expected. If faradic contractility has never 
been lost, very great and early improvement in the paralysed muscles 
may be confidently predicted. After three months but little spontaneous 
improvement is to be looked for, and after two years none at all. 

Treatment. — So little is as yet known of the mode of acquiring 
poliomyelitis that not much can be said regarding prophylactic meas- 
ures. Inasmuch as the nasal mucous membrane is known to be at least 
a possible channel of elimination of the virus, it follows that all nasal 
discharges of patients should be carefully disinfected and destroyed. 
Persons in contact with active cases should use some antiseptic nasal 
spray. Strict quarantine of sporadic cases does not as yet seem to be 
necessary. In epidemics, however, immediate quarantine should be 
instituted and strictly maintained for at least a month. Further than 
this it is not now possible to make positive statements. 

Even when recognised early, it is doubtful whether much can be 
done to limit the inflammation. The most important indication is to 
secure complete rest. Counter-irritation may be used over the spine by 
means of mustard or a Paquelin cautery, or an ice-bag may be employed ; 
yet it is very doubtful if they have any influence upon the course of 
the disease. The results depend rather upon the severity of the attack 
than the treatment employed. The natural course of the disease is to 
be kept in mind, for the tendency is to overestimate the effect upon 
the paralysis of the drugs used in the early stage. In animals if hexa- 
methylenamine (urotropin) is given simultaneously with or shortly after 
the injection of the virus in many instances no paralysis follows. Its 
curative effects in man have not yet been demonstrated. It should, how- 
ever, be tried, and administered in full doses as soon as the diagnosis can 
be made. To a child of three years from twenty to twenty- five grains 
daily may be given in divided doses. It is doubtful whether drugs have 
any influence upon the paralysis after its full development. 

After all acute symptoms have subsided, or at the end of two or 
three weeks, electricity may be used, but its curative effects have been 
very greatly overestimated. Xo amount of electrisation can preserve 
muscles whose ganglion cells have completely disappeared. These muscles 
continue to waste and lose their faradic contractility, no matter how early 
electricity is begun nor how faithfully it is continued. Faradism may 
be used for such groups as respond to it ; otherwise galvanism should be 
employed. The beneficial results from electricity are to be obtained 
chiefly in the first six months. Friction, massage, and manipulation are 
of undoubted value in improving the circulation and the nutrition of a 
limb, and should be faithfully continued twice a day for a long period. 

Mechanical Treatment. — Mechanical appliances are useful to prevent 
deformity, also to furnish support to the limb in order to enable the 
child to walk. By such means many get about with tolerable comfort 



SYRINGOMYELIA. 793 

for whom locomotion without apparatus is impossible without crutches. 
To overcome existing deformities in neglected cases, braces are employed 
in conjunction with myotomy or tenotomy of the various shortened ten- 
dons, excision of portions of elongated tendons, and the production of 
artificial anchylosis in cases of " flail joints." By these means the 
orthopaedic surgeon is able to give a great deal of relief to these unfor- 
tunate and sometimes helpless patients. 

TUMOURS OF THE SPINAL CORD. 

Tumours of the cord are exceedingly rare in childhood, and almost 
unknown in infancy. The most common varieties seen in early life are 
glioma, sarcoma, and tuberculous tumours. Eisenschitz has reported a 
case of tuberculous tumour in the dorsal region occurring in a child of 
three and a half years. There was a similar growth in the cerebellum. 
The symptoms were essentially those of compression-myelitis. 

In my service at the Babies' Hospital I had a case of glioma of 
the cord in a child only one year old, which was in many respects 
unique. The early symptoms were gradual paralysis of the upper ex- 
tremities, to which were added later, stiffness of the neck, and finally 
immobility of the head — the position being that of typical cervical caries. 
During the sixteen days of observation there was high fever, from 101° to 
104° F. There were no pupillary or vaso-motor symptoms. At the autopsy 
the cord was found to be the seat of a diffuse gliosis. In the cervical 
region there was marked enlargement, the cord being fully four times its 
natural size. A microscopical examination by Dr. C. A. Herter showed 
that the growth apparently began in the vicinity of the central canal, 
and that the gliomatous process involved the entire length of the cord. 

A somewhat similar case has been reported by Miura in a boy of 
eight years. 

The diagnosis of tumours of the spinal cord in infancy is practically 
impossible. In later childhood they are apt to be mistaken for Pott's 
disease, but the symptoms are the Fame as those seen in tumours of 
adult life. 

SYRINGO-MYELIA. 

Syringo-myelia, although a rare disease, is sometimes seen in early 
life. The term is applied to a condition in which there is a cavity in 
the cord the result of a pathological process, in contradistinction to the 
cases in which a cavity is the result of a malformation, or hydromyelus, 
although it is not infrequent for the two conditions to be associated. 
The pathological process which precedes the cavity formation is now 
thought to be, in most cases at least, an infiltration of the substance of 
the cord with gliomatous cells. The process is somewhat similar to that 
just described in the case of tumour of the spinal cord, with the excep- 



794 DISEASES OF THE NERVOUS SYSTEM. 

lion that when it results in cavity formation it is slower. The infiltra- 
tion in these cases usually begins near the central canal. It is followed 
by a degeneration and breaking down of the infiltrated areas, beginning 
at the centre. As the cavity forms it extends, and usually first invades 
the gray matter of the commissure, later the posterior gray horns, the 
posterior columns, or the anterior horns. The resulting cavity is usu- 
ally irregular in shape, and may be very small, or may extend through 
a large part of the length of the cord. It is most frequently situated 
in the lower cervical and upper dorsal regions. It is filled with fluid, 
and surrounded by gliomatous tissue. 

According to Starr, the essential symptoms are of three kinds: (1) 
There is progressive muscular atrophy, with paralysis of some or all the 
muscles of one limb, usually extending to the opposite limb and to the 
trunk, sometimes accompanied by the reaction of degeneration; (2) vaso- 
motor and trophic disturbances in the affected limb, such as cyanosis, 
coldness, bullous eruptions, ulceration, abscesses, atrophy, and sometimes 
fragility of the bones and diminution of perspiration; (3) sensory dis- 
turbances, which are probably the most characteristic symptoms of the 
disease — there is loss of the sense of pain and of temperature in the 
atrophied part, while the sense of touch and of location may be preserved. 
The extent and distribution of these symptoms will of course depend 
upon the site of the disease. 

The course of syringo-myelia is essentially chronic, the duration be- 
ing usually several } r ears; and although spontaneous arrest sometimes 
occurs the disease is in most cases steadily progressive. 

The cause is unknown, and it is not influenced by any form of 
treatment. 

FRIEDREICH'S ATAXIA. 

This is a chronic disease of the spinal cord and medulla, which begins 
most frequently in childhood or about puberty. The lesion affects first 
the posterior columns, afterward the crossed pyramidal tracts, the direct 
cerebellar tracts in the lateral columns, and Clarke's columns in the gray 
matter of the cord. There is probably some disease of the medulla, the 
pons, and possibly of the cerebellum and the posterior nerve-roots. In 
advanced cases other parts of the cord may be involved. The disease 
is seen in certain families, often affecting several members in succession 
at about the same age. It occurs particularly in families where alcohol- 
ism, insanity, and other nervous diseases are frequent. 

Bramwell, in his monograph upon this disease, gives the following 
as the characteristic symptoms: There is ataxia, first of the lower ex- 
tremities, but gradually extending to the upper extremities and the 
face. Early in the disease there is some weakness in the legs, especially 
in the anterior group of muscles. In the late stages this is marked 



LANDRY'S PARALYSIS. 795 

and accompanied by atrophy. The gait is peculiar, like that of ordinary 
ataxic patients, the difficulty in walking being due to the ataxia and not 
to the paresis. After a time there is produced a characteristic deformity 
of the foot — it is shortened, as if from pressure against the toes and 
the heel, the instep is high, and the extensor tendon of the great toe 
stands out prominently. This deformity is seen quite early in the dis- 
ease. There is often lateral curvature of the spine. The knee-jerk is 
absent. Unprovoked and uncontrollable laughter is quite a character- 
istic symptom of the disease. The patient is unable to stand with his 
eyes closed. There are palpitation, occipital headache, and sometimes 
vertigo. In the later stages speech is slow and difficult, and the patient 
talks like one intoxicated. The expression of the face is vacant, and 
often nystagmus is present. There may be choreic movements. The 
symptoms steadily progress until the patient may be helpless, although 
the general health may remain good for years. 

The disease is distinguished from locomotor ataxia by the absence 
of the " lightning pains," and of the bladder, rectal, or genital symp- 
toms, the pupillary changes, the optic-nerve atrophy, and the trophic 
changes in the bones and joints. It is distinguished from cerebral 
tumour by the absence of headache, vomiting, and optic neuritis, and 
by its longer course. The progress of the disease is slow but steady. 
It may last from twenty to thirty years. It is incurable. 



LANDRY'S PARALYSIS. 

(Acute Ascending Paralysis.) 

This rare disease is occasionally seen in early life. In regard to its 
etiology but little is definitely known, the usual causes assigned being the 
same as those of myelitis. Many cases diagnosticated Landry's paralysis 
are undoubtedly examples of poliomyelitis. There is, however, no doubt of 
the existence of an acute ascending paralysis distinct from poliomyelitis. 

It is characterised by a paralysis — sometimes preceded by general 
symptoms of malaise, fever, etc. — which begins in the legs and spreads 
rapidly to the muscles of the trunk and upper extremities ; finally it may 
involve the neck, diaphragm, and muscles of articulation. The paralysis 
develops quite rapidly, often attaining its height in from twenty-four to 
forty-eight hours, sometimes even proving fatal within this time. In 
other cases it comes on gradually, and may be two or three weeks in 
reaching its maximum. There is dyspnoea from involvement of the 
muscles of respiration. The paralysed muscles are flaccid. There is 
hyperesthesia, followed by partial or complete anaesthesia and loss of 
reflexes. There are no changes in the electrical reactions, no atrophy, 
no bed-sores, and usually no involvement of the sphincters. Occasionally 
the arms may be affected before the legs, and even the bulbar symptoms 



796 DISEASES OF THE NERVOUS SYSTEM. 

may be the first noticed. Death is the most frequent termination, and 
in fatal cases the disease lasts from two days to a week. If recovery 
takes place, it is after two or three months of illness. 

The indications for treatment are the same as in acute myelitis, for 
in the beginning the two diseases can not usually be distinguished from 
each other. 

THE MUSCULAR ATROPHIES. 

These cases may be broadly divided into two groups, following in the 
main the classification of Sachs : ( 1 ) those dependent upon disease of 
the spinal cord — the spinal atrophies; (2) those which are primarily 
diseases of the muscles themselves — the idiopathic atrophies. 

In the group of atrophies of spinal origin belong ( 1 ) the " hand 
type " of Aran and Duchenne, which has been shown to be dependent 
upon a lesion of the spinal cord; (2) the "peroneal type" of Charcot, 
Marie, and Tooth, which as yet lacks positive pathological proof of its 
spinal origin, although its etiology, symptoms, and course leave but little 
doubt that it belongs in the same category with the hand type. 

In the second (idiopathic) group are included (1) muscular pseudo- 
hypertrophy, and (2) the so-called "juvenile atrophy" of Erb, which 
is a much less frequent condition. These two varieties have the follow- 
ing features in common: There is progressive wasting, beginning early 
in childhood, and associated at some period with hypertrophy of certain 
muscles. There are no fibrillary contractions, no reaction of degenera- 
tion, and no lesions in the cord. From a pathological point of view 
these diseases might be more properly considered elsewhere, but they are 
so closely associated clinically with the spinal atrophies that it has 
seemed better to describe them in this connection. 

Progressive Muscular Atrophy of the Hand Type. — This disease is 
characterised by a very slow but progressive wasting, which usually 
begins in the muscles of the ball of the thumb of one or both hands. 
Then the palmar group of muscles belonging to the little finger are 
affected, and later the interossei. When the wasting has reached a cer- 
tain degree, there is produced a peculiar and characteristic deformity 
of the hand known as main en griff e, or " claw-hand." Following these 
muscles, those of the forearm may be affected. At this point the dis- 
ease is sometimes arrested, or the atrophy may extend to the muscles 
of the arm and shoulder, especially the deltoid, and finally to those of 
the back. Exceptionally, the atrophy begins in the muscles of the 
shoulder group or even in those of the leg. The wasting takes place 
very slowly, the muscles disappearing fibre by fibre, but the degree which 
may be reached is often extreme. The only other characteristic symptoms 
are fibrillary contractions in the muscles which are soon to atrophy. The 
patient is not conscious of them, but they are visible. The faradic 



THE MUSCULAR ATROPHIES. 797 

contractility is preserved just in proportion to the amount of muscle 
remaining. If the atrophy is complete, it is entirely lost. 

The course of the disease is a very chronic one, covering many years. 
It is incurable. In rare cases the process may extend to the muscles of 
the tongue, affecting deglutition and articulation, and death may occur 
from interference with respiration; otherwise the disease does not tend 
to shorten life. 

In this form of atrophy heredity is an important etiological factor. 
The disease may occur in children, but very often does not begin until 
after puberty. The lesion consists in an atrophy of the ganglion cells of 
the anterior horns of the spinal cord, followed by secondary degeneration 
of the anterior nerve-roots. 

Progressive Muscular Atrophy of the Peroneal Type. — This is much 
less frequent than the variety just described. In this form, the first to 
waste are the anterior muscles of the leg, especially the extensor longus 
hallucis and extensor communis digitorum, afterward the peroneal 
group. The small muscles of the foot are next affected, and the disease 
may then go on to involve the muscles of the calf. At this point it 
may be arrested permanently, or for several years, after which the thigh 
muscles may waste like those of the leg. After many years the hands 
are in some cases involved as in the type previously described, and even 
the muscles of the forearm. As a rule, the supinator longus, the muscles 
of the shoulder, neck, trunk, and face, escape altogether. The atrophy is 
generally symmetrical, but not invariably so. The cutaneous reflexes are 
usually present. There is no pain. The reaction of degeneration is 
present in some of the muscles, and fibrillary contractions are frequent, 
but not always seen. 

In this variety also the influence of heredity may often be traced. It 
is said that boys usually inherit the disease through the mother. Like 
the previous type, it begins late in childhood or not until after puberty. 

As stated above, positive proof that this disease is due to a central 
lesion in the cord is as yet lacking. Analogy, however, leads to the belief 
that it depends upon changes in the ganglion cells of the anterior horns 
in the lumbar region, similar to those found in the cervical region in the 
hand type. The course of the disease is very chronic, and it is incur- 
able. The resulting deformity resembles that seen after poliomyelitis, 
and may require the same mechanical treatment, with similar operations 
for relieving contractions. 

Muscular Pseudo-Hypertrophy (Pseudo-Hypertropliic Paralysis). — 
This is the most frequent and best-known variety of the idiopathic 
atrophies. It is a disease of certain families, often three or four children 
being affected, the boys much more frequently than the girls. The symp- 
toms as a rule come on early in childhood, nearly always before the 
tenth year. The earlier symptoms relate to a general weakness of the 



798 



DISEASES OF THE NERVOUS SYSTEM. 



lower extremities, which is accompanied by a marked increase in the 
size of certain muscular groups, usually those of the calves, but some- 
times more of the thighs or the gluteal regions. Children walk late 
and unsteadily, and fall very easily. They have special difficulty in 

rising from the floor and in mounting 
stairs. The method of rising is quite 
characteristic: the patient lifts his body 
until he touches the floor only with the 
hands and feet; then he proceeds to 
" climb up himself " by putting first one 
hand upon the knee, and then the 
other, gradually moving his hands 
higher and higher up the thighs un- 
til the erect position is attained. This 
is seen in most of the cases, but not 
in all. 

The size attained by the calves is 
sometimes very great. Gowers mentions 
a case in which a boy of twelve had 
calves measuring fourteen and a half 
inches in circumference. The enlarge- 
ment may affect almost any muscular 
group of the lower extremity. In the up- 
per extremity, the inf ra-spinatus is most 
frequently enlarged, next the supra-spi- 
natus and the deltoid. The pectorals 
and latissimus dorsi are never enlarged, 
but are generally markedly wasted. Most 
of these patients exhibit while standing 
a marked degree of lumbar lordosis, due 
to the weakness of the extensors of the 
hip. This is well shown in Fig. 156. 
The patient may be so weak upon his 
legs that the slightest touch will cause 
him to fall, even with his apparently 
immense muscular development. The 
small muscles are generally weaker than 
those which are enlarged. 
Later in the disease marked atrophy occurs with a corresponding 
weakness of all the affected groups, and the patient may be unable to 
walk or even stand. With the exception of the use of his hands, he may 
he absolutely helpless. The knee-jerk is at first normal, but gradually 
diminishes until it is finally lost. The electrical reactions are normal 
until marked wasting occurs, when there is a lessened response to fara- 




Fig. 156. — Muscular Pseudo-hy- 
pertrophy. Showing to a mod- 
erate degree the large calves and 
gluteal regions with a marked 
lordosis. (From a photograph by 
Dr. M. A. Starr.) 



THE MUSCULAR ATROPHIES. 799 

dism and galvanism, but never the reaction of degeneration. There are 
no fibrillary contractions, and no sensory disturbances. The progress of 
the disease is generally slow, and sometimes irregular. It is often more 
rapid in early childhood, and slower after puberty. Many of these chil- 
dreD, though apparently bright, are distinctly below the average for their 



The lesions are confined to the muscles. At autopsy they appear 
yellow, and microscopically there is found very marked atrophy of the 
muscle fibres, which in places have been almost entirely replaced by fat; 
there may be no trace of muscle left, the structure resembling adipose 
tissue. In other places there is an accumulation of fat between the 
atrophied muscle fibres, and a very great increase of the interstitial 
tissue. 

The prognosis is grave, most patients dying before adult life is 
reached. The diagnosis is generally easy from the apparent hypertrophy 
and actual weakness of the muscular groups. The disease is incurable. 

The Juvenile Form of Muscular Atrophy. — This is much less frequent 
than the form just described, but, like it, begins in childhood or early 
youth. It is characterised by progressive wasting of certain muscular 
groups, especially those about the shoulders and pelvis, and hypertrophy 
of others. Of the shoulder and upper extremity, the muscles affected are 
the pectorals, the trapezius, the latissimus dorsi, the serrati, the rhom- 
boidei, the muscles of the upper arm, and the subscapularis. The deltoid, 
infra-spinatus and supra-spinatus for a long time escape, and may be 
hypertrophied. The hand and forearm are not involved. In the lower 
extremity, the muscles of the pelvis, thighs, and gluteal regions are 
affected, while those of the leg and foot escape. With this atrophy there 
may be associated a true or pseudo-hypertrophy of certain muscular 
groups. In this disease there are no fibrillary contractions, no reaction 
of degeneration, and no sensory disturbances. The course and result of 
this form are essentially the same as in the preceding variety. It is now 
generally regarded as closely allied to it in its pathology, the most im- 
portant difference being that of localisation. 

There has been described, chiefly byLandouzy and Dejerine, another 
form of atrophy known as the infantile facial type. In this, wasting 
begins in the muscles of the face; the lips are thickened, but all the 
rest of the facial muscles are markedly atrophied, giving a peculiar 
expression to the mouth known as " the tapir mouth." Later, the 
atrophy extends to the shoulders and arms, but does not involve the 
supra-spinatus or infra-spinatus, or the flexors of the hand and forearm. 
This is sometimes described as beginning in the shoulders, or even in 
the legs. The description therefore corresponds to the juvenile form 
of Erb, with the addition of facial symptoms, and it is probably a variety 
of the same disease. 



800 DISEASES OF THE NERVOUS SYSTEM. 

CONGENITAL MYATONIA. 

(Oppenheim's Disease.) 

This disease was first described by Oppcnheim in 1900. It is a 
congenital condition and is usually noticed soon after birth. The strik- 
ing characteristic is the loss of muscular power which always affects the 
lower extremities and these chiefly. The arms are less frequently and 
less seriously involved. In many instances the trunk and intercostal 
muscles are also affected, but the diaphragm, the muscles of deglutition 
and those supplied by the cranial nerves usually escape. The loss of 
power is apparently complete, but by close observation a few feeble 
contractions may sometimes be made out. The limbs are flaccid and 
flail-like. The electrical reactions are feeble but the reaction of degen- 
eration is not present. All the reflexes are diminished and the patellar 
and Achilles reflexes absent. There are apparently no subjective symp- 
toms. The infants are usually well nourished and may even be very 
fat. In those who live for several months or years the intelligence is 
apparently normal and control over the sphincters complete. The major- 
ity of the children suffering from this disease die during the first few 
months frequently of pneumonia, to which they are predisposed by 
reason of the condition of the respiratory muscles. Some few that 
survive beyond this period show a slow but progressive improvement. 
How long this may continue is as yet unknown. 

The lesions are chiefly in the muscles, which may waste to fibrous 
cords or may largely be replaced by connective tissue and fat. In 
several of the cases the cells of the anterior horns of the cord have been 
reduced in number, sometimes almost absent, and the anterior nerve 
roots atrophic. The nervous lesion is regarded as a failure of develop- 
ment rather than a degeneration. It is believed by some to be the 
primary condition, the lack of muscular development being the result 
of deficient innervation. Little can be expected from any form of 
treatment. 



CHAPTER V. 
DISEASES OF THE PERIPHERAL NERVES. 

MULTIPLE NEURITIS. 

Under the term multiple neuritis are included those cases in which 
several nerves are involved in an inflammatory process, which may at 
times be general. In its distribution multiple neuritis is usually sym- 
metrical, but it is not necessarily so. 

Etiology. — The chief cause of multiple neuritis in children is diph- 
theria, although it is occasionally seen after other infections diseases, 



MULTIPLE NEURITIS. 801 

especially malaria, typhoid or scarlet fever, measles, and mumps. In 
diphtheria the inflammation is due to the direct action of the toxines 
upon the nerve structures, since it can be induced in animals by injecting 
toxines into the circulation. There is little doubt that in all infectious 
diseases the inflammation is excited in a similar way. The metallic 
poisons, lead and arsenic, are rarely the cause of multiple neuritis in 
early life, and the same is true of alcohol, although a marked case from 
this cause has come under my observation in a child only three years old. 1 
Lastly, there are cases in which the cause assigned is simply exposure 
to cold — those classed as rheumatic. 

Lesions. — Almost any nerves in the body may be affected, although 
the distribution varies somewhat with the cause of the disease. The 
musculo-spiral and the anterior tibial nerves are most frequently in- 
volved, but the inflammation may affect any of the spinal nerves, includ- 
ing the phrenic, and occasionally the cranial nerves, especially the pneu- 
mogastric, hypoglossal, oculomotor, and abducens. Several nerves in 
different parts of the body are usually affected, the lesion being in most 
cases symmetrical. 

The affected nerve is sometimes red and swollen, owing to acute con- 
gestion and oedema or a sero-fibrinous exudation. In other cases the 
changes are almost entirely degenerative. The microscope shows the 
changes sometimes to be chiefly interstitial and sometimes chiefly paren- 
chymatous. There is an exudation of cells into the sheath, between the 
sheath and the nerve fibres, and even between the nerve fibres themselves. 
The nryeline breaks up into granules, and in places may completely dis- 

1 This case was in many respects a remarkable one. The boy completely emptied 
a decanter containing twelve ounces of whisky, but almost immediately vomited the 
greater part of it. He soon after showed the symptoms of alcoholic intoxication, and 
in a few hours became comatose, in which condition he continued for twelve hours. 
After this he gradually lost power in his legs, and at the end of a week was unable to 
walk at all. He had convulsions, and after this there developed the usual symptoms 
of meningitis at the convexity, with which he was admitted to the Babies' Hospital, 
three weeks after drinking the whisky. The child was then unconscious and there 
was present incomplete paralysis, affecting all four extremities, with anaesthesia of 
the arms. The active inflammatory symptoms continued for six weeks longer, 
during which time there were repeated convulsions, continuous stupor, fever, gradu- 
ally increasing deformities, marked atrophy, loss of reflexes, and great diminution in 
the faradic contractility of all the paralysed muscles; in the thighs, left leg, and 
abdominal muscles there were no responses to a strong current, but there was nowhere 
the reaction of degeneration. The child was at death's door for three or four weeks. 
Three months after the attack the first signs of improvement were observed in the 
cerebral symptoms. Shortly afterward he began to use his hands, and at the end of 
six weeks he was walking alone and talking freely. The improvement was very 
rapid, and eight weeks from the date of the first change for the better, and five months 
from the time of taking the whisky, he was as well as ever. The diagnosis was mul- 
tiple alcoholic neuritis, with a convexity meningitis. (Fig. 157 is from a photograph 
taken while the symptoms were at their height.) 
52 



S02 



DISEASES OF THE NERVOUS SYSTEM. 



appear. The late changes are those of subacute or chronic degeneration 
of the nerve fibres. 

With these changes in the nerves there are associated, in some cases, 
inflammatory and degenerative changes in the ganglion cells of the 
spinal cord, although they are much less severe than are the lesions in 
the nerves. However, they were once regarded as the explanation of 
some of these cases, particularly of diphtheritica paralysis. 

Symptoms. — The onset of multiple neuritis is in most cases a grad- 
ual one, it being usually from two to four weeks before the paralysis 
reaches its height. Very exceptionally the onset may be abrupt, with 
fever, and marked paralysis in a few days. It is characteristic of this 
disease that both motor and sensory symptoms are present, and that they 
are the same in their distribution. The symptoms are usually symmet- 
rical. There is first noticed a general weakness in the affected muscles, 
which slowly increases to complete paralysis. As the extensor groups 
of the hands and feet are apt to be affected, there are wrist-drop and 
foot-drop (Fig. 157). The paralysis may begin in the feet and hands, 




Fig. 157. — -Alcoholic Neuritis, showing Characteristic Dropping of the Feet. 
This position of the lower extremities was maintained for over a month. Boy three 
years old. 



and gradually extend until it involves not only the four extremities, but 
even the muscles of the trunk and the neck, although this is rare. The 
child may then be absolutely helpless, unable to sit up, or even to support 
his head. In such cases the head seems loosely attached to the body, and 
rolls about on the shoulders like a ball. Weakness of the spinal muscles 
leads to deformities (Fig. 158), which I have seen mistaken for Pott's 
disease, even by experienced observers. In most of the muscular groups 
the paralysis is incomplete. The symptoms which relate to the phrenic 
and the cranial nerves will be described with Diphtheritic Paralysis, for 
they are rarely seen in any other form. It is characteristic of multiple 
neuritis that the bladder and rectum escape. 



MULTIPLE NEURITIS. 



803 



The sensory symptoms are marked only in the early stage of the dis- 
ease, while the paralysis is increasing; they improve so much more rap- 
idly than the motor symptoms, that they 
may be altogether wanting at the time 
that the paralysis is at its height. In 
some cases they are so slight as to be 
overlooked. There is nsnally pain along 
the course of the affected nerves, which 
is sharp and neuralgic in character, and 
generally associated with acute tender- 
ness of the nerve trunks and of the mus- 
cles. Often there is a general hyperes- 
thesia in the early part of the attack, 
followed by partial anaesthesia. The 
sensations of touch, pain, temperature, 
and the muscular sense are all about 
equally affected. 

Ataxia is not uncommon, and may 
be a more striking symptom than the 
loss of power. All the reflexes are di- 
minished or lost, especially the knee- 
jerk, as the legs are usually most af- 
fected. Sometimes, particularly after 
diphtheria, there is loss of the knee-jerk, 
when there is no other symptom of neu- 
ritis. In the severe cases muscular tre- 
mor is frequent. 

Atrophy is a prominent symptom of 
neuritis, and it is evident early in the 
disease, often being quite as rapid as in 
poliomyelitis. The electrical reactions 
are altered — every grade of reduction in 
the responses being seen, from a slight diminution in the reaction to fara- 
dism to the complete reaction of degeneration. Yaso-motor symptoms, 
such as oedema of the affected parts, glossiness of the skin, etc., are often 
present. Deformities from muscular contraction occur early; they may 
be severe, and in some cases, permanent. 

Course and Prognosis. — The usual course of the disease is for the 
symptoms gradually to increase for three or four weeks and then im- 
prove, sometimes rapidly, but more often slowly, the case usually going 
on to complete recovery in the course of a few months. Exceptionally 
the paralysis may be permanent. The sensory symptoms always disap- 
pear before the motor ones. Multiple neuritis may prove fatal, from 
paralysis of the heart or the muscles of respiration, or death may be due 




Fig. 158. — Multiple Neuritis 
after Diphtheria in a Child 
Four Years Old. The position 
of the head and spine is due to 
partial paralysis of the trunk and 
neck. The legs were also affected. 



804 DISEASES OF THE NERVOUS SYSTEM. 

to asphyxia from the entrance of food or foreign bodies into the air 
passages, owing to anaesthesia of the epiglottis and paralysis of the mus- 
cles o( deglutition. Death sometimes follows from complications, espe- 
cially pneumonia. The electrical reactions are of much prognostic value 
in regard to the persistence of the paralysis. If the reaction of degenera- 
tion is present the paralysis is certain to last many months, and some 
muscles are sure to be permanently affected. Where there is simply a 
diminution in the faradic responses, even though accompanied by marked 
atrophy, complete recovery may be expected, although it is often slow. 

Diagnosis. — The diagnostic features of multiple neuritis are the com- 
bination of motor and sensory symptoms with the same distribution, the 
occurrence of atrophy, and the diminution in the electrical responses, 
even the reaction of degeneration. The gradual onset and the wide- 
spread distribution of the paralysis are also characteristic. If all four 
extremities are paralysed, it is altogether the probable disease ; and if to 
this is added paralysis of the neck and spinal muscles, the diagnosis is 
almost certain. The facts that the paralysis is often incomplete, and 
that it involves parts distant from each other, are also important. 
Neuritis may be mistaken for poliomyelitis, for Landry's paralysis, or for 
Pott's paraplegia ; an important diagnostic point from the last mentioned 
is the condition of the reflexes — being greatly exaggerated in Pott's 
paraplegia, while they are diminished or lost in multiple neuritis. 

Treatment. — As this disease tends in the great majority of cases to 
spontaneous recovery, it is difficult to estimate the value of any method 
of treatment. Causes, such as lead, arsenic, alcohol, and malaria, are to 
be sought and removed as the first step. During the acute stage the pain 
may be so severe as to require relief, which is best accomplished by the 
application of heat. In using counter-irritation care is necessary, and 
such active measures as cauterisation should not be employed, for trouble- 
some ulceration may follow. After the acute stage has passed, or at 
the end of three or four weeks, electricity should be begun, faradism 
being used if the muscles respond to a moderate current, otherwise gal- 
vanism. This should be continued daily until recovery. Strychnine is 
much used in these cases, but it is doubtful whether it has any specific 
influence, although as a tonic it is valuable. Other tonics, such as iron, 
quinine, and cod-liver oil, should also be given. Massage is also bene- 
ficial. The spinal treatment of cardiac and respiratory paralysis will be 
discussed in the following article. 

DIPHTHERITIC PARALYSIS. 

This is not only the most frequent variety of multiple neuritis, but 
it has some peculiarities which make a separate consideration of it 
desirable. 



DIPHTHERITIC PARALYSIS. 805 

Frequency. — According to the statistics of various observers, paralysis, 
including all varieties, occurs after diphtheria in from 5 to 15 per cent 
of the cases. Sanne gives 11 per cent in 2,448 cases; Lennox Browne, 14 
per cent in 1,000 cases (in neither of these groups did the patients receive 
antitoxine) ; the Report of the Collective Investigation by the American 
Pediatric Society, 9.7 per cent of 3,384 cases which were treated by 
antitoxine. 

It is difficult to state to what degree the frequency of paralytic 
sequelas after diphtheria is affected by the antitoxine treatment. The 
figures above given might indicate that the protective power of the serum 
over the nervous tissues is not so great as over others, and that unless 
administered very early it has little or no influence. The more probable 
explanation of the frequency with which paralysis is seen after antitoxine 
treatment is that patients now live long enough to develop paralysis, 
when without antitoxine the same patients would have died during the 
early stage of the disease. 

Being one of the direct effects of the diphtheria toxine, neuritis is 
much more likely to follow severe than mild cases; however, its occur- 
rence after some very mild attacks shows how great is the susceptibility 
of the nervous tissues to the action of this poison. Sometimes the throat 
symptoms have been entirely overlooked, and the development of paraly- 
sis has been the first thing to arouse a suspicion of previous diphtheria. 

Time of Occurrence. — During the second week, and sometimes even 
during the latter part of the first week, the early paralysis occurs, usu- 
ally affecting the palate. The most frequent and most characteristic 
paralysis — that affecting the throat, eyes, extremities, and respiration — 
begins at a later period, usually from one to three weeks after the throat 
has cleared off, and sometimes even later than this. 

Extent and Distribution of the Paralysis. — Ross gives the following 
statistics of 171 collected cases of diphtheritic paralysis: Palate affected 
in 128; eyes in 77, in 54 of which the muscles of accommodation were 
involved; lower extremities in 113; upper extremities in 60; trunk or 
neck in 58; muscles of respiration in 33. I do not think this repre- 
sents the actual frequency of the different varieties so truly as do the 
American Pediatric Society's figures, which give the forms of paralysis 
noted in a series of cases collected for another purpose. In 328 cases of 
paralysis, the variety was mentioned in 189 ; in 124 the throat was 
affected; in 22 the extremities; in 11 the eyes; in 5 the muscles of respi- 
ration; in 32 the heart; in 1 the neck only; in 8 the paralysis was 
" general." 

Symptoms. — In the great majority of cases the throat is affected, and 
usually the paralysis is first noticed there. It may involve the palate 
alone, or the muscles of the pharynx or larynx in addition. The muscles 
of the extremities or of the eve are often next attacked. In severe cases 



806 DISEASES OF THE NERVOUS SYSTEM. 

there may also be involved the muscles of the trunk and neck, and some- 
times the diaphragm. It is this which distinguishes diphtheritic paralysis 
from other forms of multiple neuritis. Whatever the extent or situation 
of the paralysis, the knee-jerk is nearly always lost. The symptoms in the 
extremities and the trunk do not differ from those of multiple neuritis 
from other causes. The throat paralysis shows itself by a nasal voice and 
by regurgitation of fluids through the nose, sometimes by difficulty in 
swallowing or by the entrance of food into the larynx, owing to anaesthesia 
of the epiglottis and paralysis of the muscles of deglutition. There may 
be difficulty in protruding the tongue or in articulation. Facial paralysis 
is very rare. On the part of the eye there is most frequently seen in- 
ability to read, owing to paralysis of the muscles of accommodation ; there 
may be dilatation of the pupils, rarely strabismus or ptosis. 

Respiratory paralysis may be due to involvement of the phrenic or the 
intercostal nerves, more frequently the former. Extensive paralysis of 
other parts — the throat, extremities, or trunk — usually precedes. The 
first warning is generally in the form of occasional attacks of dyspnoea, 
sometimes accompanied by cough. Gradually these attacks increase in 
frequency and severity. The voice is reduced to a whisper. As the 
diaphragm is usually affected, the breathing is entirely thoracic. The 
respiratory movements are rapid, but irregular, shallow, and ineffectual. 
There is cyanosis, also great subjective as well as objective dyspnoea. 
The anxiety, distress, and apprehension of the patient are sometimes 
terrible. There is a constant dread of impending suffocation, and the 
respiratory movements are continued only by the patient's constant ef- 
forts, otherwise they would cease altogether. After a few hours these 
severe symptoms may subside, to return after a short respite. There 
may be several such attacks during two or three days, in each of which 
death seems imminent. Unfortunately, this is the most frequent termi- 
nation. Of thirty-three such cases collected by Ross, only eight recovered. 
Associated with these respiratory symptoms others may be present. There 
may be attacks of abdominal pain, vomiting, and disturbance of the heart's 
action — usually an irregular or intermittent pulse, which may be either 
unnaturally slow or very rapid. In many cases the heart continues to 
beat normally, even though the respiration is so much disturbed. 

The premonitory symptoms of cardiac paralysis are an irregular or 
intermittent pulse, often slow, but becoming very rapid from even the 
slightest exertion. It is always weak and compressible. The first sound 
of the heart is feeble and may be reduplicated. As the symptoms increase 
there are marked pallor, coldness of the extremities, great restlessness, 
anxiety, precordial distress, and perhaps orthopncea. Within twenty- 
four hours from the beginning of such symptoms death usually occurs. 
In other cases it may come suddenly without any warning, or with a 
warning so slight as to be overlooked. At such times it often follows 



FACIAL PARALYSIS. 807 

some muscular exertion, such as getting out of bed, walking across the 
room, or so slight an effort as sitting up suddenly in bed. Fits of temper 
or other excitement have at times produced it. It is by no means cer- 
tain that cardiac paralysis is due to a lesion of the cardiac nerves. 
Toxic myocarditis appears to be a more important factor in producing 
the fatal result. 

Death in diphtheritic paralysis is usually due either to cardiac or 
respiratory paralysis. Of 171 cases of all varieties collected by Eoss, 
forty-five were fatal. 

Treatment. — Cases of paralysis of the trunk or extremities are to be 
managed like others of multiple neuritis. In severe forms of throat 
jparalysis feeding by a stomach tube should be employed, on account of 
the danger of the entrance of food into the air passages. It must in 
most cases be continued for several days. The tube may be passed 
either through the mouth or the nose. 

The great mortality attending paralysis of the heart and respiration 
shows how unsuccessful is treatment in most of the cases ; still, no doubt 
there are instances where life may be saved by judicious treatment. In 
cases of threatened heart paralysis, the drug most to be depended upon 
is morphine, hypodermically ; this should be used every two or three 
hours in sufficient doses to keep the patient under its influence while 
threatening symptoms are present. The patient should lie kept abso- 
lutely quiet, not even being allowed to turn in bed. In respiratory 
paralysis the general reliance is upon strychnine used hypodermically 
in full doses, and faradisation of the respiratory muscles, particularly 
the diaphragm. 

FACIAL PARALYSIS. 

Peripheral paralysis of the face occurring as a result of injury in- 
flicted daring delivery has already been described. There remain to be 
considered here cases which arise from causes that operate at a later period. 
The facial nerve may be affected in any one of three situations — after its 
exit from the cranium, in the bony canal, and within the cranium. 

In the first situation, the principal cause of neuritis is exposure to 
cold (the "rheumatic" cases), but it occasionally occurs as a complica- 
tion of mumps and disease of the lymph glands of this region. The nerve 
is affected just after it has escaped from the stylo-mastoid foramen, and 
all the branches given off beyond its exit are involved. There is paralysis 
of the muscles of the forehead, those about the eye, cheek, nose, and 
mouth. The affected side of the face is smooth, there is inability to 
wrinkle the forehead, contract the eyebrows, close the eye completely, 
raise the nostril, whistle, or blow. The mouth is drawn to the healthy 
side (Fig. 159). If the paralysis is complete, there may be difficulty 
in drinking or in articulation. In partial paralysis the symptoms may 



SOS 



DISEASES OF THE NERVOUS SYSTEM. 




Fig. 159. — Facial Paralysis of Right 
Side from Middle-ear Disease in a 
Child Two and a Half Years Old. 



not be noticeable while the face is at rest. There are no sensory symp- 
toms. The electrical reactions resemble those of other forms of neuritis ; 
there is diminution in the response to the faradic current, which is more 

or less marked according to the se- 
verity of the lesion, and there may 
be the reaction of degeneration. 

In the bony canal, the facial 
nerve is usually inflamed as a result 
of disease of the ear. In children 
this is much more frequent than 
from the other causes just men- 
tioned. While it occasionally occurs 
with acute otitis, it generally accom- 
panies the chronic form with caries 
of the petrous bone which is very 
often tuberculous. In addition to 
the paralysis there is present or 
there is a history of a discharge from 
the ear, and generally there is some 
deafness upon the side affected. The 
facial symptoms are usually the 
same as in the cases first described. 
However, when the nerve is affected between the stapedius and the genicu- 
late ganglion, there is a disturbance of the sense of taste, and of the secre- 
tion of saliva. Facial paralysis also occurs as a result of injury to the 
nerve during the mastoid operation. 

At the base of the brain the trunk of the nerve may be involved in 
cerebral tumour, basilar meningitis, and in fracture of the skull. In 
any of these conditions the auditory nerve also is likely to be affected. 
Prognosis. — The result is greatly modified by the causes in the dif- 
ferent cases. In those which are due to cold, spontaneous recovery usu- 
ally occurs in the course of a few weeks or months. In those depend- 
ing upon disease of the ear, the outlook is not so favourable, and though 
there may be improvement, it is not rare for some paralysis to be per- 
manent. In the third group of cases, facial paralysis is only one of the 
symptoms, and the result depends entirely upon the nature of the cause. 
Diagnosis. — Facial paralysis is easily recognised. It is important to 
separate the peripheral paralysis from that due to a lesion above the 
pons, as in eases of ordinary hemiplegia. In the latter group only the 
lower half of the face is affected, the muscles of the forehead and those 
about the eye escaping, and the electrical reactions are unchanged. 

Treatment. — This is essentially the same as in other cases of neuritis. 
In cases due to ear disease the primary lesion should receive appropriate 
treatment. 



SECTION VIII. 

DISEASES OF THE BLOOD, LYMPH NODES, SPLEEN, BONES, 

AND JOINTS. 

CHAPTER I. 
DISEASES OF THE BLOOD. 

Theee are several particulars in which the blood of infancy and 
early childhood differs from that of older persons. 

Specific Gravity. — This has no constant relation to the number of 
white or red corpuscles, but varies with the amount of haemoglobin. The 
highest specific gravity is seen in the blood of the newly born. During 
the first two weeks of life it sinks rapidly to its lowest point, where it 
remains until about the end of the second year; after this time it rises 
gradually until about puberty. The average specific gravity during 
childhood is 1.050 to 1.055. 

Haemoglobin. — The percentage of haemoglobin is highest in the blood 
of the newly born, and falls rapidly during the first few days after birth. 
Throughout childhood it is considerably lower than in adult life. The 
haemoglobin is lowest between the third month and the second year; 
after the second* year it gradually increases up to puberty. The usual 
range in young children, as measured by the adult standard, is between 
sixty-five and eighty-five per cent, sixty-five per cent being a low limit 
in healthy children. 

Red Corpuscles. — The number of red corpuscles is highest in the 
newly born. At this time it is from 4,350,000 to 6,500,000 in each cubic 
millimetre. In infancy it is from 4,000,000 to 5,500,000 ; in later child- 
hood, from 4,000,000 to 4,500,000 (Hay em). In size a much greater 
variation is seen in the red cells of the newly born than in those of older 
children and adults. In the blood of the foetus there are present nucle- 
ated red corpuscles or normoblasts (Plate XV, A). These diminish in 
number toward the end of pregnancy. They are always found in the 
blood of premature infants, but in infants born at term they are seen 
only in small numbers and disappear after a few days. In later infancy 
their presence is always pathological. 

Normal White Cells. — The following varieties are found in health: 

1. Lymphocytes. — These are small cells about the size of a red blood 
cell. The protoplasm is small in amount, forming merely a narrow rim 

809 



810 DISEASES OV THE BLOOD. 

about the nucleus; it stains with basic dyes rather more deeply than does 
the nucleus. The nucleus is relatively large, is centrally situated, and 
shows at times one or two nucleoli. The protoplasm may have a reticu- 
lar structure. These cells form in adults from twenty-two to twenty- 
live per rent of the white corpuscles, but in children they are often as 
high as fifty or sixty per cent (Plate XV, B, 10). 

•J. Large Mononuclear Leucocytes and Transitional Forms. — These 
cells are two or three times the size of ordinary red cells (Plate XV, D, 
10). The oval nucleus is not so centrally situated as in the lymphocytes, 
and stains feebly but rather more deeply than the protoplasm, which is 
poorly stained by basic dyes. The protoplasm is homogeneous and rela- 
tively Large in amount. 

The transitional forms occasionally contain a few feebly staining neu- 
trophilic granules ; their nuclei are bent or curved and stain more deeply. 

• I. Polymorphonuclear Ncutropliiles. — These are smaller than the 
Large Leucocytes (Plate XV, B and C, 8). The nucleus consists of three 
to four parts, usually connected by narrower portions, and stains darkly. 
The protoplasm stains with acid dyes and shows a great number of 
granules which stain only with neutral dyes. In adults these cells form 
about seventy per cent of the white cells; but in children they are less 
numerous, the increase in the lymphocytes being at the expense of the 
neutrophils. 

4. Eosinophiles. — These are about the same size as the neutrophiles 
(Plate XV, C, 9); they have deeply staining nuclei, usually divided 
into two parts. The protoplasm has many large granules that stain 
deeply with acid dyes, and often a narrow outer layer stains more 
deeply than the rest. They form from two to four per. cent of the total 
number of white cells. 

5. Mast Cells. — They are only occasionally found, their proportion 
being about 0.5 per cent of the white cells; they are mononuclear or 
polymorphonuclear cells whose granules stain only with basic dyes, not 
at all with tri-acid; often they are metachromatic (Plate XV, C, 12). 

Pathological White Cells.— Of these there are two principal forms: 

1. Myelocytes. — They have neutrophilic granules and a single rounded 
nucleus (Plate XV, C, 11). Ehrlich's myelocytes differ from those of 
Cornil in that the cells as a whole are smaller, the nuclei are more 
centrally situated and stain more intensely. 

2. Mononuclear Eosinophiles. — These resemble the poly nuclear eosin- 
ophiles, except for the round undivided' nucleus. 

Pathologically, any of the leucocytes may undergo acute or chronic 
degeneration, with swelling and fragmentation, nuclear changes, hydropic 
degeneration, etc. 

The a in,, her of leucocytes in the blood of the newly born, according 
to Bieder, is a1 birth from 1 t,200 to 27,400 per cubic millimetre; from 



PLATE X\ 




B. 




Drawn by Dr. F. C. Wood. 



A. Blood of an Eight-Months' Fcetus. 
C. yon Jaksch's Anemia. 

1. Red cells, normal. 

2. Red cells, normoblasts. 

3. Red cells, megaloblasts. 

4. Red cells, showing mitosis. 

5. Red cells, poikilocytes. 

6. Red cells, granular degeneration. 



B. Simple Anemia. 

D. Acute Lymphatic Leukemia. 

7. Red cells, polychromatpphilia. 

8. White cells, polynuclear neutrophil* 

9. White cells, eosinophiles. 

10. White cells, lymphocytes. 

11. White cells, myelocytes. 

12. White cells, mast cells. 



LEUCOCYTOSIS. 811 

the second to the fourth day, from 8,700 to 12,400; after the fourth day, 
from 12,400 to 1 t,800. The variations in infancy are from 9,000 to 

14,000, and in later childhood from 6,000 to 12,000. 

LEUCOCYTOSIS. 

By leucocytosis is meant an increase in the white corpuscles of the 
blood. This may relate to all or any of the varieties; although it is 
chiefly of the polymorphonuclear neutrophils, there is seen in children 
a greater tendency than in adults to an increase in the lymphocytes. 

It is customary to distinguish between physiological leucocytosis, 
such as that which follows a full meal, exercise, cold baths, or that which 
occurs in the newly-born infant, and pathological leucocytosis which 
occurs principally in inflammatory and toxic conditions, but may be seen 
also in malignant disease and after serious haemorrhage. Digestive 
leucocytosis, that which occurs after feeding, is especially pronounced 
in children, the increase frequently amounting to thirty-three per cent 
of the total number of leucocytes present. Leucocytosis of the newly 
born has already been mentioned. 

Leucocytosis is present in a great variety of pathological conditions. 
In many of them its significance is not yet fully understood; further 
study of it has not fulfilled the expectations of those who had hoped to 
obtain from it exact information regarding many pathological processes. 

The form of leucocytosis which is chiefly important in children is the 
inflammatory. This is most marked in acute pneumonia, diphtheria, 
and in inflammations attended by the formation of pus. Leucocytosis 
is also frequently present in scarlet fever, erysipelas, acute rheumatism, 
septic and cerebro-spinal meningitis, and in many other conditions. 
Of the purulent inflammations, it is especially important in appendicitis, 
peritonitis, empyema, pyaemia, osteo-myelitis, and all acute abscesses. 
In the conditions above mentioned the increase is chiefly or exclusively 
in the polymorphonuclear neutrophiles. 

There are other conditions, especially pertussis, hereditary syphilis, 
and certain diseases of the spleen, in which the proportion of the lympho- 
cytes may be increased. 

The eosinophiles are increased in leukaemia, in asthma, with intestinal 
parasites especially tapeworm, hookworm and trichinae, and in some 
forms of chronic skin disease. 

As a rule, leucocytosis is absent in typhoid fever, measles, malaria, 
influenza, and in tuberculous inflammations. It is wanting in the usual 
forms of gastro-enteritis of infants although it is marked in the type 
known as " Finkelstein's food intoxication." 

Leucocytosis may be regarded as the reaction of the organism to the 
toxines in the blood elaborated by the bacteria concerned in the inflam- 
mation or infection, or to the bacteria themselves. It thus depends 



812 DISEASES OF THE BLOOD. 

upon two factors: the Beverity of the infection, and the amount of re- 
sistance oi' the individual, the latter being the more important A severe 
infection with a high degree of resistance produces the mosl marked 
leueocytosis, while with very feeble resistance and the same infection the 
leucocytosis is slighl or possibly absent. The degree of leucocytosis is also 
influenced by the nature of the inflammatory process, it being less marked 
in Berous inflammations and more pronounced in suppurative processes. 
In inflammations it is usually greatest during the active stage of exu- 
dation. 

The Diagnostic Value of Leucocytosis. — The following are the prin- 
cipal diseases in which a leucocyte count may be of clinical assistance: 

Appendicitis. — A leucocytosis usually exists from the beginning; a 
marked or steadily increasing leucocytosis is to be regarded as an im- 
portant indication for operation. 

Pneumonia. — A marked leucocytosis is a characteristic feature of 
this disease; the exceptions are very mild cases or very severe infections 
with little or no reaction. The increase begins shortly after the onset 
and continues during the stage of exudation, generally reaching its 
maximum shortly before the crisis, when it declines rapidly. The usual 
number of white cells in an average case of pneumonia in a young child 
is from 15,000 to 30,000, but it is not rare for the count to run up to 
40,000 or even 50,000. I have seen it over 100,000. The absence of 
leucocytosis in a strong child who is acutely ill is always strong presump- 
tive evidence against pneumonia. A well-marked leucocytosis is of much 
value in differentiating pneumonia from typhoid fever, tuberculosis, 
influenza, or bronchitis. 

Empyema. — A rapid increase in the leucocytes in the active stage of 
a pneumonia or after defervescence, in the absence of physical signs 
pointing to an extension of the pneumonic process, almost invariably 
indicates empyema. After the acute stage of empyema has passed there 
may be no leucocytosis whatever. 

Typhoid Fever. — Leucocytosis is regularly absent in typhoid; its 
presence in an undoubted case indicates complications. 

Pertussis. — A leucocytosis with a high proportion of lymphocytes is 
of considerable value in the diagnosis of this disease; it is more fully 
considered in the special chapter devoted to Pertussis. 

Meningitis. — As a rule, a marked leucocytosis is present in all forms 
of acute meningitis except the tuberculous. In the latter variety it is 
not constant, and if present is generally less marked than in the other 
forms. 

Tuberculosis. — Leucocytosis is regularly absent in unmixed tuber- 
culous infections. It is occasionally found in tuberculous meningitis. 

In surgical diseases the presence of leucocytosis is considered a reli- 
able guide as to the existence of acute suppuration, although not always 



SIMPLE AN.KMIA. 813 

as to its degree. An increasing leucocyte-sis is usually an indication for 
operative interference in cases where operation is admissible. This 
applies particularly to appendicitis. 

SIMPLE ANEMIA. 

This consists in an impoverishment of the blood, especially the red 
cells, and a corresponding diminution in the specific gravity and in the 
amount of haemoglobin. It is essentially a secondary anaemia, and occurs 
apart from disease of the blood-making organs. Infancy and childhood 
are themselves strong predisposing causes of anaemia, on account of the 
great demands made upon the blood in the rapid growth of the body. 

Etiology. — The causes of anaemia embrace a wide range of patholog- 
ical conditions. A child born of a delicate mother or of one suffering 
from tuberculosis or syphilis may show marked anaemia at birth. It may 
follow any severe haemorrhage or occur in any of the blood dyscrasiae, 
purpura, scurvy, etc. ; also, the severe drain of prolonged suppuration, 
chronic nephritis, large serous effusions, many forms of diarrhoea and in 
malignant disease. Anaemia is often of toxic origin, sometimes being 
due to mineral poisons — lead, mercury, or potassium chlorate; more 
frequently it arises as the result of absorption of the products of ex- 
cessive intestinal putrefaction. Certain of the specific infections, nota- 
bly diphtheria, malaria, tuberculosis and rheumatism, produce a marked 
degree of anaemia, as one of their effects; also some of the intestinal 
parasites, particularly varieties of the tapeworm and hookworm. 

Much more frequent in young children than any of the above are the 
anaemias due to improper feeding, rickets, and unhygienic surround- 
ings. How important these causes are and how severe a grade of anaemia 
may be produced by them, i» not usually appreciated. The physician is 
often led to suspect some serious organic or constitutional disease when 
none exists and to overlook such common conditions and obvious causes 
as those mentioned. Anaemia is seen when lactation is unduly prolonged. 
It is a frequent result of the long-continued use of milk or infant foods 
as the sole diet, given, as these often are, throughout the second or third 
year, for the reason that the child will take no solid food, because he 
is allowed to have the bottle. Lack of fresh air, confinement to over- 
heated rooms and the crowding of young children in hospitals and insti- 
tutions are common and important causes of anaemia. 

Symptoms. — Anaemic children usually exhibit many symptoms of 
malnutrition. Their tissues are flabby ; they are generally below average 
weight and suffer from digestive disturbances and chronic constipation. 
The associated nervous symptoms are many : headaches, indefinite pains, 
insomnia or disturbed sleep, general irritability and a high degree of 
nervousness. There is easy fatigue, shortness of breath on exertion, and 
sometimes fainting attacks. The peripheral circulation is poor ; the hands 



S| 1 DISEASES OF THE BLOOD. 

and feel are often cold. The pulse may be slightly irregular. Anaemic 
murmurs are hoard over the base of the heart or the large vessels, and 

may he so loud even in infancy as to be mistaken for organic disease. 
A venous hum is sometimes heard in the neck. Epistaxis is not uncom- 
mon. The urine is Bcanty and sometimes pale. There may be enuresis. 
(Edema is rare in older children, but in severe anaemias of infancy it is 
often marked. In a certain number of cases, even of moderate severity, 
the spleen is much enlarged. Pallor of the skin and mucous membranes 
is present in most cases, hut is not an accurate guide as to the degree of 
anaemia. This tan only be determined by an examination of the blood. 

The Blood. — There is a reduction of the number of red cells and to 
a still greater degree in the haemoglobin. In a case of moderate severity 
the red cells are from 4,000,000 to 4,500,000, and the haemoglobin from 
fifty to sixty per cent. In severe cases the red cells may fall to 2,000,000 
or 8,500,000 or even lower, and the haemoglobin to twenty or thirty per 
cent. These figures are not uncommon. The lowest I have seen is a 
reduction of the haemoglobin to fifteen per cent and of the red cells to 
1.400,000. The red cells are pale. There is usually poikilocytosis and 
anisocytosis ; and, especially in infancy, a few normoblasts and megalo- 
cytes may be found (Plate XV, B). 

There is generally a slight leucocytosis. The differential count of 
the white cells shows an increase in the lymphocytes, chiefly the small 
variety; the polymorphonuclear cells are relatively reduced in number. 

Prognosis. — The course and termination of anaemia depend upon its 
cause. If this is one that can be removed, as in cases depending upon 
improper feeding and surroundings, very rapid improvement often takes 
place and prompt recovery. In the most severe cases death may occur, 
rarely from the anaemia, usually from some .complicating disease. 

In making a prognosis in a given case the general symptoms and the 
cause of the anaemia are much more important than the examination of 
the blood. If the digestive organs are in good condition and good sur- 
roundings can be secured, often, though the haemoglobin and red cells 
are very greatly reduced, the prognosis is good. But in unfavourable 
surroundings and with a greatly disordered digestion, the outlook is 
much more serious. 

Typical blood examinations of a moderate and of a severe case of 
secondary anaemia in a young child are as follows: 

Severe Anaemia. 



Hemoglobin 20 per cent. 

Red blood cells 2,500,000 

White cells 12,000 

Polymorphonuclear 30 per cent. 

Small mononuclear 45 per cent. 

Large mono nuclear 25 per cent. 

Other forms 5 per cent. 



Moderate Anemia. 

Haemoglobin 50 per cent. 

Red blood cells 4,000,000 

White cells 10,000 

Polymorphonuclear 40 per cent. 

Small mononuclear 25 per cent. 

Large mononuclear 20 per cent. 

Other forms 5 per cent. 



CHLOROSIS. 815 

The treatment of all the forms of anaemia will he considered together 
at the close of the chapter. 

CHLOROSIS. 

Chlorosis is a primary or essential anaemia which usually occurs in 
young girls about the time of puberty. It is characterised by a peculiar 
greenish-yellow tint of the skin, and is not accompanied by emaciation. 
The changes in the blood consist in a very great reduction in the haemo- 
globin without a corresponding diminution in the red corpuscles. 

Etiology. — The exact cause of chlorosis is not yet understood. The 
disease rarely occurs in males; it is usually seen in girls between the 
fourteenth and seventeenth years, and more often in blondes than in 
brunettes. Heredity appears to be a factor in some cases. Other causes 
are occupations deleterious to health, such as employment in factories 
or confinement in ill-ventilated rooms; insufficient food or clothing; 
psychical disturbances, like grief, care, or fright; excessive mental or 
physical strain, and disorders of menstruation — although the latter are 
perhaps more frequently a result than a cause of the disease. Virchow 
first called attention to the fact that chlorosis might depend upon a 
congenital narrowing of the aorta, sometimes associated with a small 
heart. It is difficult to reconcile this etiology with the rapid recovery 
under appropriate treatment which is seen in most of the cases. Andrew 
Clark has advanced the view that the chief cause of chlorosis is constipa- 
tion and the resulting absorption of toxic materials from the intestine. 

Lesions. — Chlorosis is rarely fatal. In the few fatal cases the lesions 
noted have been dilatation of the right heart with hypertrophy of the left 
ventricle, a small aorta, small uterus and ovaries, and occasionally round 
ulcer of the stomach. Under the microscope there may be found a very 
marked degree of fatty degeneration of the heart muscle, and sometimes 
of the inner coat of the blood-vessels. 

Symptoms. — The general symptoms of chlorosis are very much like 
those of simple anaemia. There are observed shortness of breath upon 
exercise, palpitation, syncope, attacks of vertigo, disturbances of diges- 
tion, amenorrhcea, and almost invariably constipation. The appetite is 
capricious, it being a peculiarity of these patients to crave all sorts of 
indigestible articles. Instead of the usual pallor of anaemia, the skin 
has a yellowish-green tint, from which the term " green-sickness " has 
arisen. Occasionally patches of pigmentation are seen. Anaemic cardiac 
murmurs may be heard in various situations, most frequently a systolic 
murmur at the base of the heart, and usually loudest over the pulmonic 
area. There may be a venous hum in the neck. In some marked cases 
there is evidence of slight cardiac dilatation, especially of the right 
heart, and there may be hypertrophy of the left ventricle. The pulse is 
weak and soft, oedema of the feet is frequent, and sometimes there is 



816 DISEASES OF THE BLOOD. 

slight albuminuria. In some cases there is fever. Nervous disturbances, 
such as vague, indefinite pains, attacks of migraine, supra-orbital neu- 
ralgia, various hysterical manifestations, and chorea, are common. Ulcer 
of the stomach is sometimes seen as a complication. 

77/,' HI ood. — The specific gravity is reduced in proportion to the loss 
of haemoglobin. The characteristic feature of chlorosis is a loss of haemo- 
globin which is out of proportion to the reduction in the red cells. The 
haemoglobin in an ordinary case is frequently as low as thirty-five or 
forty per cent, while the red cells may be 3,500,000 to 4,000,000, or even 
higher. 

Morphologically the cells are pale with a wide central clear area. 
Poikilocytosis may be present, but is not marked; rarely normoblasts 
may be found. The presence of megalocytes is disputed. The leuco- 
cytes are usually unchanged in number and proportion, but the lympho- 
cytes may be relatively increased. 

Prognosis. — The course of the disease is essentially a chronic one, 
often lasting for a year. Eelapses are quite frequent. Except when de- 
pendent upon congenital malformations of the heart and blood-vessels, 
these cases regularly recover when proper treatment can be carried out. 
A small number prove fatal by the development of tuberculosis or the 
occurrence of gastric ulcer. 

Diagnosis. — A probable diagnosis is in most cases easily made from 
the etiology, the functional derangement of the heart, the colour of the 
skin, and a positive diagnosis always by an examination of the blood. 

PSEUDO-LEUKiEMIC ANEMIA OF INFANCY. 

This form of anaemia was first described by Yon Jaksch in 1889, and 
is by him believed to be peculiar to infants and young children. It is 
characterised by marked leucocytosis, marked reduction in the number 
of red cells and in the haemoglobin, a great enlargement of the spleen, 
and sometimes a moderate enlargement of the liver and the lymphatic 
glands. This disease is not to be confounded with the pseudo-leukaemia 
of adults, or with liodgkin's disease, which is a disease of the lymphatic 
glands with secondary anaemia, but without any leucocytosis. 

The existence of pseudo-leukaemic anaemia as a distinct disease is 
denied by most of the authorities on diseases of the blood. It is to be 
regarded as a symptom-complex. All the reported cases can be classed 
as severe secondary anaemia, pernicious anaemia, or leukaemia. 

Etiology. — Of the cases thus far recorded the majority have been 

bet ween the ages of seven and twelve months. Of twenty cases collected 

[onti and Berggriin, sixteen showed evidences of rickets and one 

syphilitic. The exact cause of the disease is still unknown, and 

ssential nature ie a mat to- of some doubt. Monti believed that it 



PSEUDO-LEUKjEMIC anaemia of infancy. 817 

might develop from the more severe cases of anaemia which are accom- 
panied by leucocytosis, as he observed this condition before the devel- 
opment of pseudo-leukaemia and during its subsidence. 

Lesions. — The most characteristic change is found in the spleen, 
which is very much enlarged, often forming an abdominal tumour of 
considerable size. It is firm, hard, and there may be evidences of peri- 
splenitis. The microscope shows a simple hyperplasia. Enlargement of 
the liver is less constant, it being normal in more than half the cases. 
There is no relation between the size of the spleen and that of the liver. 
The hepatic cells are unchanged. Enlargement of the lymph glands has 
been noted in about half the reported cases, the swelling affecting the 
cervical, axillary, or inguinal glands; but it is rarely great. Inconstant 
changes in the bone-marrow have been described. 

Symptoms. — The Blood. — The number of reported cases is as yet too 
small to make positive statements possible upon all points. The main 
features noted thus far are the following (Plate XV, C) : 

The specific gravity is lowered, the usual range being between 1.035 
and 1 . 044. The reduction of the haemoglobin is very great ; in many of 
the cases it has been as low as thirty per cent, and in a few below twenty- 
five per cent. 

The red cells are always diminished ; in six of twenty cases they were 
below 1,600,000 (Monti and. Berggriin). There is also great inequality 
in their size and shape. Nucleated red cells are found in considerable 
numbers; as a rule, these are chiefly normoblasts, but when the anaemia 
becomes more severe, it is usually the megaloblasts that predominate. 
The leucocytes vary from 20,000 to 50,000. They may show an increase 
in the mononuclear or in the polynuclear forms. The eosinophiles are 
usually increased, but not to the extent to suggest leukaemia. All vari- 
eties of cell degeneration are found. 

The general symptoms of the disease develop slowly and with the 
usual signs of anaemia. In some cases the infants continue to be plump 
and well nourished. Pallor is usually very marked. Enlargement of 
the spleen is so great that it can hardly be overlooked if the abdomen is 
examined. The glandular enlargements are not marked, and in many 
cases are wanting altogether. 

The course of the disease is essentially chronic. Cases have been seen 
in which pseudo-leukaemia developed from an ordinary severe simple 
anaemia in the course of a few weeks. The symptoms and blood changes 
generally come on slowly in the course of weeks or months, and some- 
times remain nearly stationary for as long a period as several months, 
and then slowly improve. In other cases they grow gradually worse. In 
the cases going on to recovery, there is noticed improvement in the gen- 
eral symptoms coincident with a diminution in the size of the spleen, a 
reduction in the number of leucocytes, an increase in the red cells, the 
53 



Sis DISEASES OF THE BLOOD. 

hemoglobin, and the Bpecific gravity, and a gradual disappearance of the 
nucleated rod tolls. 

Prognosis.— In Monti's list of twenty cases four proved fatal; one 

ered, in which the proportion of leucocytes to the red cells had 

been one to twelve. The prognosis should be guarded, for, although 

improvement may take place, many patients die from intercurrent 

disease. 

PERNICIOUS ANAEMIA. 

This is the most severe form of anaemia known. Its cause and essen- 
tial nature are as yet very imperfectly understood. It is characterised by 
quite uniform blood changes and by the general symptoms of a very 
marked anaemia, and it tends to go on from bad to worse, terminating 
fatally in the great proportion of cases. 

Etiology. — Pernicious anaemia is a rare disease in childhood, and 
especially rare in infancy. In the cases which have been observed in 
early life the following etiological factors have been noted: It has been 
associated with hereditary syphilis and with severe rickets, especially 
when accompanied by a marked enlargement of the spleen. It has fol- 
lowed other diseases, especially grave disturbances of nutrition. Some- 
times simple anaemia, when severe and of long standing, has gradually 
developed into the pernicious type. In a few instances parasites, partic- 
ularly tapeworms, have been the cause. Pernicious anaemia has in some 
instances occurred in patients when no cause whatever could be assigned. 

Many theories have been advanced in explanation of pernicious anae- 
mia. The one which at present appears to have most in its favour is 
that the disease consists in a great destruction of the red blood-cells, 
particularly in the liver, and that this is brought about through the 
agency of some poison or poisons taken up from the intestine by the 
portal circulation. This has been advanced by Hunter and others in 
explanation of the peculiar deposit of iron found in the hepatic cells. 

Lesions. — There is found a very high grade of anaemia in all the in- 
ternal organs, fatty degeneration of the heart and blood-vessels, and 
sometimes also of the liver and kidneys, with numerous capillary haemor- 
rhages in the various organs. The most characteristic post-mortem 
change, however, consists in the deposit of iron in the hepatic cells. Its 
distribution is peculiar and unlike that seen in any other disease. The 
bone marrow is also markedly altered. 

Symptoms. — The Blood. — The specific gravity of the blood in perni- 
cious anaemia is constantly and considerably reduced, and its coagulabil- 
ity is feeble. The haemoglobin is always reduced, usually it is as low as 
from twenty to thirty per cent. The red cells are always much dimin- 
ished in number and generally to a degree greater than the reduction in 
the haemoglobin. Their number is seldom greater than 2,000,000, and 



PERNICIOUS ANAEMIA. 819 

frequently less than 1,000,000. Megalocytes arc, present, often in great 
numbers, and a preponderance of them is regarded essential to the 
diagnosis. Microcytes are rare. It is characteristic of pernicious anae- 
mia that owing to the relatively high haemoglobin content the red cells 
stain well, usually deeper than in normal blood. A striking feature of 
these cases is the presence of extreme poikilocytosis. Nucleated red cells 
are also present, megaloblasts in greater numbers than normoblasts. The 
red cells do not collect to form rouleaux. 

The total number of leucocytes is markedly diminished, but the lym- 
phocytes may be relatively increased. An occasional myelocyte may be 
found. 

The general symptoms are those of a most intense anaemia. There 
is marked pallor of the skin and mucous membranes, with great weak- 
ness and prostration. Various anaemic heart murmurs are heard. There 
is dyspnoea, and usually the urine is scanty and of low specific gravity. 
There may or may not be emaciation. The late symptoms are haemor- 
rhages from the nose and other mucous membranes, subcutaneous ecchy- 
moses with dropsy of the feet and ankles, and sometimes of the large 
serous cavities of the body, but without albuminuria. In many cases 
fever is present. This may be so high as to lead to the suspicion of 
some acute infectious process. 

The course of the disease is, as a rule, more rapid than in adults, 
the duration being in most cases but a few months ; it is marked by 
periods of exacerbation and remission. During the exacerbations all the 
symptoms are intensified, and as a rule some fever is present. During 
the remissions marked improvement may take place in all the symptoms 
and an increase in the haemoglobin and red cells occur. In general, the 
progress of the disease is downward and sometimes the rate is very rapid. 
The only exceptions are the cases in which the disease depends upon 
some intestinal parasite, when improvement and even recovery may 
occur. 

Treatment of the Different Forms of Anaemia. — In secondary ancemia 
the thing of the first importance is to discover and treat the primary 
condition upon which the anaemia depends. In infanc}^, special atten- 
tion should be given to diet and hygiene, particularly with reference to 
an abundant supply of fresh air. The whole manner of life of these 
patients must be carefully studied and managed according to the direc- 
tions laid down in the chapter upon Malnutrition, with which condition, 
especially in infancy, a very large number of these cases are associated. 
The general treatment referred to is often more important than the 
administration of the preparations of iron, which, however, should never 
be omitted. 

The preparations of iron available for infants are the albuminate, 
bitter wine, sweet wine, saccharated carbonate, malate, and citrate. The 



DISEASES OF THE BLOOD. 

should be regulated according to the age of the child. Older chil- 
dren may take the same preparations as adults, especially reduced iron 
and Bland's pills. Much benefit is seen from combining arsenic with iron, 
or from alternating the two. In addition to these remedies, cod-liver oil 

should he given if the condition o\' the digestive organs will permit. 

In chlorosis more decided results are seen from the use of iron than 
in any other form of anaemia. Bland's pills are here the favourite method 
of administration, and are advantageously combined with small doses 
o( mix vomica and aloin to overcome the tendency to constipation. 
Arsenic is useful in these cases also. Great benefit in chlorosis results 
from change of air and change of scene, thus removing the patient 
from all sources of nervous excitement or disturbance. The general con- 
dition, diet, and habits of life should also receive careful attention, 
particularly the condition of the bowels. 

Oxygen is a valuable adjuvant in the treatment of all anaemias not 
yielding to iron alone. It is important that the administration of iron 
should be continued for several months after the disappearance of all 
symptoms, on account of the tendency to relapse. 

In the pseudo-leul'ce.mic aimmia of infants, arsenic is decidedly the 
most valuable drug, but should be given in combination with iron. 
Fowler's solution is the best preparation for infants; the dose should 
rarely be more than one drop, which should be repeated four or five 
times daily after feeding, and continued for a long time. The general 
treatment of these patients is the same as in cases of simple anaemia. 
When rickets is present cod-liver oil and phosphorus should be added. 

In pernicious ancemia, arsenic offers a much better prospect of im- 
provement than does iron. Beginning with small doses, the amount 
should be gradually increased up to the point of tolerance, very much 
as in cases of chorea. 

In every case of anaemia the most careful attention should be given 
to the general condition, particularly guarding against exposure to cold 
and dampness. The feeble circulation of these patients renders them 
peculiarly susceptible. Caution should also be given against much mus- 
cular exercise. 

In many cases of anaemia of a severe grade, whether primary or sec- 
ondary, transfusion offers a brilliant prospect of improvement and even 
recovery when no other treatment is of any avail. 

LEUKAEMIA. 

This is a disease in which the essential feature is a great increase in 
the number of leucocytes, with a moderate reduction in the number of 
red corpuscles, and the presence in the blood of cellular forms not found 
in health. 



LEUKEMIA. 821 

Etiology. — Leukaemia is a rare disease in childhood, but it lias been 
seen even in early infancy. Its greater frequency in males holds good 
even in childhood. In a small Dumber of cases heredity seems of some 
importance as an etiological factor. Leukaemia may follow syphilis, 
rickets, malaria, or even simple anaemia, or it may occur as a primary 
disease in children previously healthy. The cause is unknown. 

Lesions. — The essential lesions of leukaemia are found in the spleen. 
the lymphatic glands, and the hone-marrow. In rare cases the most 
important changes are in the lymphatic glands, giving rise to the 
lymphatic form of leukaemia. In such cases the changes in the spleen or 
marrow may be slight or absent. Changes in the spleen and marrow are, 
however, usually associated, giving rise to what is known as the spleno- 
myelogenous form of the disease, which is the most frequent variety. 
The spleen is usually enormously enlarged, sometimes filling half the 
abdominal cavity. In the early stage it is soft, vascular, and of a dark- 
red colour; in the late stages it is firm and hard, and usually deeply 
fissured at its margin. There may be perisplenitis. On section, light- 
gray patches of lymphoid tissue may be seen scattered throughout the 
organ, and in some instances there may be wedge-shaped infarctions. 
The microscope shows thickening of the trabecular and deposits of lym- 
phoid tissue, especially about the arteries. In the lymphatic form any 
of the external glands of the body may be affected, the cervical, axil- 
lary, and the inguinal, or the mesenteric, tracheo-bronchial, the tonsils, 
and even the lymph nodules of the tongue, pharynx, and intestines. The 
changes in the glands are generally those of a simple hyperplasia. The 
liver is enlarged in very many of the cases, chiefly from an infiltration 
with lymphoid tissue, which may be diffuse or may occur in patches. 
Less frequently similar lymphoid masses are seen in other organs. 

Symptoms. — The Blood (Plate XV, D). — The colour is lighter than 
normal and its coagulability usually diminished. Generally the red 
cells are much reduced in number, although not to the extent seen in 
pernicious anaemia. The most important feature is the great increase 
in the number of leucocytes, which vary in form according as the type is 
spleno-myelogenous or lymphatic. The red cells are usually of normal 
size and a moderate number of normoblasts is found ; the haemoglobin is 
diminished. 

In the spleno-myelogenous form the white cells may be from 100,000 
to 500,000, but, especially under the influence of arsenic, a marked tem- 
porary diminution may occur, so that their number may be scarcely above 
the normal; both Ehrlich's and Condi's myelocytes are present, and the 
presence of a large number of these is pathognomonic. The number of poly- 
morphonuclear neutrophils is greatly increased, although their propor- 
tion is diminished. The eosinophils are very much increased in number, 
mononuclear forms being present. The number of lymphocytes is in- 



822 DISEASES OF THE BLOOD. 

creased, but they vary according to the type and stage of the disease; 
this is true also of the Large mononuclear leucocytes. Mast cells are 
much increased in number, this being the most reliable diagnostic sign. 

In the lymphatic form the lymphocytes alone are increased, so that 
the other white rolls are relatively diminished. The increase is usually 
in the small lymphocytes, which form from eighty to ninety per cent of 
the leucocytes present. Myelocytes and mast cells are either present in 
small numbers or absent altogether. 

The other symptoms of leukaemia in children resemble those in 
adults, with the difference that, as a rule, the progress of the disease is 
much more rapid in early life. In most of the cases the early symptoms 
are latent. A sudden and alarming haemorrhage is sometimes the first 
thing to call attention to the serious condition. In other cases there are 
only the symptoms of general weakness and anaemia. Sometimes the 
splenic tumour or the enlargement of the lymphatic glands is first no- 
ticed. In the early part of the disease, the usual symptoms of anaemia 
are present — digestive disturbances, shortness of breath, weak and rapid 
pulse. Haemorrhages may occur as an early or late symptom; they are 
most frequently from the nose, but severe haemorrhages may occur from 
the stomach, the mouth, the intestines, or there may be ecchymoses upon 
the skin. The enlargement of the spleen may be sufficiently marked to 
form an abdominal tumour, so as to attract the attention even of the 
parents. The swelling of the liver is not so great. The lymphatic glands 
are enlarged only to a moderate degree, and in many cases this symptom 
is absent altogether. They are painless, movable, and usually several 
groups are affected. 

The late symptoms are dropsy of the feet or general anasarca, haemor- 
rhages, diarrhoea, headaches, general weakness, and attacks of fainting. 
Fever is quite constant in the late stages of the disease, and the tem- 
perature may be from 101° to 103° F. The urine may contain albumin 
and casts. Vision is sometimes disturbed by the formation of leukaemic 
plaques in the retina. It is rare that there are any symptoms referable 
to the bones, although expansion and tenderness of the flat bones have 
been observed. 

Course and Prognosis. — The course of leukaemia is chronic, and in 
mosl cases slowly progressive, but not always so. The prognosis is very 
bad, the great proportion of the cases in children proving fatal within a 
year from the first symptoms, in infancy sometimes in two or three 
months. There has been described by Epstein and others an acute form 
of the disease, proving fatal in a few weeks. The usual causes of death 
are exhaustion, haemorrhages, and broncho-pneumonia. 

Diagnosis. — This, in children, has to be made chiefly from simple 
anaemia with leucocytosis, and pseudo-leukaemic anaemia. Without a 
blood examination this is impossible. The chief reliance is to be placed 



HAEMOPHILIA. 823 

upon the enormous increase in the leucocytes, and especially upon the 
presence of numerous mast cells and myelocytes. 

Treatment. — The general treatment of leukaemia should be the same 
as that of anaemia. Of the drugs now in use, arsenic has altogether the 
most testimony in its favour. It must be given in large doses and for a 
long period. Next to this in value come iron and cod-liver oil. Leu- 
kaemia, however, is in most instances very little influenced by treatment. 
The reported cures must be taken with some allowance, for most of these 
were published before the time when leukaemia was sharply differentiated 
from simple anaemia with leucocytosis and from the pseudo-leukaemic 
anaemia of infancy. 

HEMOPHILIA. 

Haemophilia is an hereditary disease, in which there is a tendency to 
profuse or even uncontrollable bleeding from slight wounds, or some- 
times even spontaneously. In many cases there is associated an inflam- 
mation of the joints. Persons so affected are known as " bleeders." 

Etiology. — The hereditary tendency of the disease is very strongly 
marked, and it has often been traced through seven or eight generations. 
Males are much more frequently affected than females, the proportion 
being about twelve to one. In the matter of inheritance, the disease is 
most often transmitted through the mother, who, however, usually es- 
capes herself. Patients suffering from haemophilia may have nothing else 
about them that is abnormal. The exact nature of the disease is un- 
known. It has no connection with either purpura or scurvy. Although 
generally classed among the diseases of the blood, it has not been estab- 
lished that there are any constant changes either in the blood or in the 
blood-vessels. But there is probably either a deficiency of some element 
of the blood necessary to produce coagulation, or possibly an excess of 
some element interfering with coagulation. 

Symptoms. — The first manifestations of haemophilia are not often 
seen before the second year. The haemorrhages of the newly born have 
no relation to this condition. The discovery of the disease is generally 
quite accidental. The first haemorrhage may be traumatic or spontane- 
ous. In traumatic haemorrhages there may be very severe bleeding after 
so slight a wound as the drawing of a tooth; sometimes a large haema- 
toma forms between the muscles as the result of a moderate contusion. 

The following is the relative frequency of spontaneous haemorrhages 
in 334 cases collected by Grandidier: Bleeding from the nose in 169, 
mouth in 43, intestines in 36, stomach in 15, urethra in 16, lungs in 17. 
There may be haemorrhage from the skin or from any mucous membrane 
of the body. The attacks of spontaneous haemorrhage are often peri- 
odical, and may be accompanied by arthritic symptoms resembling 
rheumatism. The severity of the haemorrhages varies much in the dif- 



824 DISEASES OF THE BLOOD. 

tVivni cases. From a slight wound a patient may bleed until he is ex- 
sanguinated, and even until death occurs. Such a result from the first 
hemorrhage, however, is rare. In some cases the disposition to bleed 
is outgrown in later lite. Grandidier states that, of 152 boys, over one- 
half died before reaching- the seventh year. It is striking that when the 
disease affects females there is no tendency to excessive bleeding at men- 
struation or parturition. 

Treatment. — The indications at the time of bleeding are, to arrest 
the haemorrhage by the use of the ordinary surgical means — especially 
compression. Calcium lactate and gelatine may be used as described 
in the haemorrhages of the newly born; but little benefit is to be ex- 
ported from drugs. In extreme cases transfusion may be practised. Its 
effects are sometimes very striking. In convalescence after attacks of 
haemorrhage, iron and general tonics should be given. In all patients 
who are bleeders everything which might by any means excite haemor- 
rhage should be avoided. The marriage of girls who inherit the disease 
should be discouraged. 

PURPURA. 

The term purpura is used to designate a condition in which there is 
a tendency to spontaneous haemorrhages beneath the skin, from the 
various mucous membranes, and in some cases into the internal organs. 
The term purpura simplex is applied to those cases in which the haemor- 
rhages are limited to the skin; purpura hemorrhagica to those in which 
there is in addition bleeding from the mucous membranes or visceral 
haemorrhages. It is impossible to draw a line sharply between these two 
classes of cases, as the chief difference between them seems to be one of 
degree. Purpura is sometimes known as morbus maculosus or as Werl- 
hofs disease. 

Symptomatic Purpura. — This occurs in quite a variety of conditions, 
the haemorrhages generally being limited to the skin, but not always so. 
These cases may be grouped in the following classes : 

1. Infectious. — This form of purpura is very constantly seen in 
malignant endocarditis, in the haemorrhagic forms of the various erup- 
tive fevers — measles, scarlet fever, variola, vaccinia, and typhus — also in 
epidemic meningitis and occasionally in diphtheria, pyaemia, and sep- 
ticaemia. The occurrence of haemorrhages in these cases appears to 
depend upon an altered condition of the blood, which is a direct result of 
the infection, and it is a bad prognostic sign. 

2. Cachectic. — Purpura occurs late in the course of many protracted 
and exhausting diseases, especially in infancy. It is most frequently 
met with in broncho-pneumonia, empyema, tuberculosis, ileo-colitis, in 
both the tuberculous and the simple forms of meningitis, and in malig- 
nant disease. It also occurs from apparently similar causes in several 



PURPURA. 825 

of the diseases of the blood, particularly in leukaemia and pernicious 
anaemia. In most cases of cachectic purpura the haemorrhagic spots are 
small, not very abundant, and occur either upon the abdomen or the 
lower extremities. This form is quite common in hospital practice, and 
is almost invariably indicative of a fatal result. In cachectic purpura 
the haemorrhages are usually limited to the skin. The condition is un- 
doubtedly dependent upon a deterioration in the blood, possibly also 
upon the condition of the minute blood-vessels. 

3. Toxic. — Certain drugs, such as phosphorus, quinine, potassium 
chlorate, and sometimes others, may in rare cases produce haemorrhages 
when long continued or in large doses. The haemorrhage of jaundice 
may also be considered in this group. 

4. Mechanical haemorrhages, such as those occurring in pertussis or 
epilepsy, are sometimes classed with purpura. In convalescence from 
protracted illness there are sometimes seen, when patients first stand or 
walk, purpuric spots on the lower extremities. They may occur after the 
confinement of a limb in bandages or splints. In both these cases the 
cause is partly mechanical and partly due to the weakened condition of 
the blood-vessels. 

5. Neurotic. — These cases are occasionally seen in diseases of the 
spinal cord and sometimes in hysteria in young adults, but very rarely 
in children. 

Primary Purpura. — This occurs in children of all ages, being not un- 
common in infancy. Haemorrhages of the newly born have not gener- 
ally been included in this class, although there are some reasons why they 
might well be. The age at which primary purpura is most frequently 
seen is from two to ten years. The sexes are about equally affected; 
of Steffen's 56 cases, 27 were males and 29 females. The disease may 
occur in children who are cachectic, rachitic, or anaemic, and in those 
whose surroundings are poor, but it has not, like scurvy, any close rela- 
tion to diet. It may follow any acute disease, being associated most 
frequently with derangements of the stomach and bowels. Quite often 
the disease develops abruptly, without any assignable cause, in children 
previously healthy. 

Lesions. — The external haemorrhages may occur upon any part of 
the body. There are smaller or larger ecchymoses or an infiltration 
of the tissues with blood, which undergoes gradual absorption with the 
usual changes. With the haemorrhages, various forms of inflammation 
of the skin may be associated, especially erythema and urticaria, with 
sometimes more or less oedema. Haemorrhages from the mucous mem- 
branes are more frequent, because of the feebler resistance of the tissues. 
There are seen ecchymoses upon the visible mucous membranes which 
resemble those upon the skin. At autopsy they are occasionally seen 
in the trachea or bronchi, but more often in the digestive tract. In 



826 DISEASES OF THE BLOOD. 

Dion, and occasionally in the small intestine, ulcers may be found; 
but they are rarely, if ever, seen in the stomach. They may be super- 
ficial or deep, and have even been known to cause perforation. 

Intracranial hemorrhages are rare, and are usually meningeal. 
These mav be sufficient to cause severe symptoms. I saw one at the 
New York Infant Asylum in an infant six months old, with an extensive 
meningeal haemorrhage covering a large part of the brain. In Steffen's 
paper several such cases are mentioned. 

Pulmonary hemorrhages are not frequent. Ecchymoses are found 
beneath the pericardium; but endocarditis and pericarditis are ex- 
tremely rare, probably occurring only in the rheumatic cases. The spleen 
is occasionally enlarged, but by no means uniformly so, and it may be 
the seat of haemorrhages. 

While hematuria is one of the most frequent of the visceral hemor- 
rhages, severe nephritis is rare. Acute degeneration of the renal epithe- 
lium of the tubes is quite common. There may be punctiform hemor- 
rhages, and occasionally larger ones beneath the capsule or in the 
mucous membrane of the pelvis of the kidney. The suprarenal capsules 
may be the seat of extensive and even fatal hemorrhage. There may 
be effusions of a sero-sanguineous fluid into any of the large serous 
cavities, most frequently into the peritoneum. The articular lesions 
of purpura may be of a rheumatic character, with which purpura occurs 
as a complication; or there may be hemorrhages into the tissues about 
the joint, or even into the joint itself — usually the knee or elbow. 

Thus far no constant or essential changes have been demonstrated 
in the blood, other than those which are due to hemorrhages — viz., a 
moderate reduction in the hemoglobin and the red corpuscles, with oc- 
casional irregularities in size and the appearance of nucleated red cells. 
In the most severe cases there is a moderate degree of leucocytosis. 

Pathology. — Why it is that under certain circumstances the blood- 
vessels will not hold their contents, it is difficult to understand. There 
have been described by Cassel, Riehl, Wilson, and others, changes in the 
small blood-vessels, usually a form of endarteritis, but it is not necessary 
to assume a lesion in the blood-vessels, since we know that diseased 
blood may pass through even normal vessels. Henoch has suggested 
the vaso-motor origin of purpura, in which there is first a paralytic dis- 
tention of the small vessels, followed by stasis, hemorrhage, or edema. 
In certain forms, as in malignant endocarditis, it is well established that 
the cause is an infectious thrombosis. Although the bacteriological ex- 
aminations made thus far in purpura are not numerous enough to settle 
the question positively, there is little doubt that infection is the essen- 
tial factor in some forms of the disease, particularly in the cases charac- 
terised by sudden onset, high temperature, and cerebral symptoms, and 
which run a rapidly fatal course. At the present time the exact pathol- 



PURPURA. 827 

ogy of purpura is unknown. There are, no doubt, now included under 
this term several diseases quite distinct from one another. 

The Clinical Types. — 1. The Ordinary Form. — In the mild cases the 
haemorrhage is confined to the skin (purpura simplex), or it is accom- 
panied by slight bleeding from the mucous membranes. There is usually 
some general indisposition of an indefinite character for a day or two 
before the purpuric spots are noticed; most frequently a disturbance of 
digestion with vomiting, diarrhoea, and sometimes slight fever. The 
haemorrhages appear as small petechia?, varying in size from a pin's 
head to a pea. usually first upon the lower extremities. There may be 
only a few widely scattered spots or the body may be covered. The 
colour is first a bright red, then purple, gradually fading in the course 
of a few days. Xew spots come as the old ones disappear, so that the 
amount of eruption may not diminish. They do not disappear upon 
pressure. 

The course of these cases is generally favourable, recovery taking 
place in from one to four weeks under the influence of general tonic 
treatment. Relapses are, however, very frequent, and such attacks may 
come at intervals of a few weeks or months for a considerable period. 
One must be guarded in giving an absolutely favourable prognosis even 
in cases of such severity, for it occasionally happens that in a patient 
who for several days has had symptoms of mild purpura, there suddenly 
develop those of the most severe type with a rapidly fatal termination. 

2. The Severe Form. — Such cases are characterised by haemorrhages 
from the mucous membranes (purpura haemorrhagica ) from the outset. 
These may even appear before the spots upon the skin. In severe at- 
tacks the petechial spots are more likely to appear suddenly, and large 
ecchymoses, varying in size from a pea to the palm of the hand, are more 
frequent. There may be bleeding from the nose, gums, mouth, or 
pharynx, and ecchymoses may be seen upon these mucous membranes, 
also upon the conjunctivae. Vomiting of blood and bloody discharges 
from the bowels are quite frequent symptoms. The urine may contain 
enough blood to give it a bright-red colour. Less frequently there are 
seen haemorrhages of the retina or choroid and from the female genitals. 
In one of my own cases there was almost continuous bleeding from one 
ear. Cutaneous ecchymoses are increased by slight injuries, such as the 
pressure from a bandage or from scratching. Epistaxis may be copious 
enough to necessitate plugging of the nares. The amount of blood vom- 
ited is not often large ; its source may be the stomach, the mouth, or the 
pharynx. The blood in the stools is usually dark coloured, but there may 
be some bright-red blood even when there are no ulcers present. In one 
of my cases so much blood was lost by the bowels as to produce the symp- 
toms of a very marked cerebral anaemia. In certain cases the gastro- 
intestinal symptoms are very prominent, and there may be slight icterus. 



sjs DISEASES OF THE BLOOD. 

The discharge of blood from the Btomach or intestine may be accom- 
panied by very severe attacks of colic and tenesmus. In some of these 
there are pains and slight swelling of the joints. Eenal symptoms 
nerallv present. The attacks of abdominal pain with purpura and 
the discharge of blood may come on paroxysmally every few days for a 
period o\' several weeks. They have been ascribed to thrombosis of the 
intestinal vessels. This is sometimes known as "Henoch's purpura. " 

Constitutional symptoms are present in most of the severe cases. 
There is usually fever, from 101° to 103° F., and sufficient prostration 
to keep the patient in bed. If the amount of blood lost is large, there 
are the usual symptoms of severe anaemia. The loss of blood may be 
sufficient to cause death, particularly in infants. Cerebral symptoms 
may depend upon anaemia or upon meningeal haemorrhage. They are 
not frequent in this form of the disease. (Edema, especially of the face 
and feet, may exist without albuminuria, and albuminuria may be pres- 
ent in eases in which there is no renal haemorrhage. 

In some of the cases beginning with severe general symptoms, and 
occasionally when the onset is mild, the patients after a few days pass 
into a typhoid condition with low delirium, great prostration, weak and 
irregular pulse, dry, cracked tongue, and high temperature. Such cases 
are almost always fatal. They are not to be confounded with ordinary 
typhoid fever complicated by purpura. 

The course varies much in the different cases. It lasts from one to 
six weeks, the symptoms slowdy subsiding, but often showing a strong 
tendency to recurrence. The prognosis depends upon the age of the 
patient, the extent of the haemorrhage, and the presence or absence of 
septic symptoms. 

3. The Hyper-acute Form (purpura fulminans). — This is a rare 
form, especially in young children. Its development is usually sudden, 
with a chill, vomiting, marked prostration, and high temperature. The 
purpuric spots come out with great rapidity, and in the course of a 
few hours "or a day they may be very extensive. In addition to the 
ordinary subcutaneous haemorrhages, bloody vesicles may form upon the 
skin. In many cases the haemorrhages are limited to the skin, the mu- 
cous membranes and the viscera escaping altogether. There is no 
tendency to gangrene. Cerebral symptoms are invariably present and 
usually prominent; there may be delirium, dulness, stupor, and finally 
coma. The spleen is apt to be enlarged. The urine is nearly always 
albuminous. This form of purpura has all the characteristics of a gen- 
eral infectious disease, and it is almost invariably fatal. 

4. The Gangrenous Form. — Sloughing is not common in purpura, 
but it is most often seen in the mucous membranes. Osier refers to two 
cases affecting the uvula. I once saw a slough which caused perforation 
of the soft palate. Wickham Legg reports a case with gangrene of the 



PURPURA. 829 

prepuce. Gangrene of the skin is even less frequent, although cfi 
have been reported even in young children. Charron's case was only 
three years old, and several others in children are collected in Gimard's 
monograph upon this subject. The gangrene may involve the skin only, 
or the subcutaneous tissues, and even the muscles. It has been seen 
upon the upper and lower extremities, and even upon the face, and may 
extend over quite a large surface. In some of the milder forms of pur- 
pura, gangrene results from some slight injury, such as a blow, the pres- 
sure from a bandage, or, in the nose, from the pressure of a tampon. 
These cases are almost invariably fatal. Those in which the sloughing 
is confined to small areas of the mucous membrane of the mouth often 
recover. 

5. The Rheumatic Form. — The term "rheumatic purpura" (peliosis 
rheumatica) is applied to cases, not so common in children as in older 
patients, in which subcutaneous haemorrhages, and sometimes bleeding 
from the mucous membranes, are associated with painful joint swell- 
ings. These are to be regarded as cases of rheumatism complicated by 
purpura. The joints most frequently affected are the knee and the 
ankle. The arthritic symptoms are usually less severe than in attacks 
of acute rheumatism. There may be present erythema exudatrvum or 
erythema nodosum or urticaria. Usually there are throat symptoms 
and fever, and frequently oedema of the face and eyelids with albu- 
minuria. The spleen may be enlarged. The usual duration is from one 
to three weeks, and although relapses may occur, the cases usually 
recover. 

Joint symptoms, particularly articular pains, are not infrequent in 
the course of milder attacks of purpura without the febrile symptoms 
mentioned. In severe cases extravasations of blood have been reported 
as occurring in the tissues about the joints, and even in the joints them- 
selves, these being cases of true arthritic purpura. It is probable that, 
in the past, some cases of scurvy have been included in this group. 

Diagnosis. — The rapid acute cases may be confounded with the haem- 
orrhagic forms of the various eruptive fevers. The ordinary subacute or 
passive forms are chiefly to be differentiated from scurvy. The diag- 
nosis is not difficult, and the mistake need not be made if the essential 
features of scurvy are borne in mind — its dietetic cause, bleeding gums, 
hyperaesthesia, and deep rather than subcutaneous haemorrhages which 
are usually near the joints. 

Prognosis. — This depends very much upon the form of the disease. 
Of 128 cases of all varieties occurring in children in Steffen's collection, 
there were 40 deaths. In 12 cases of severe primary purpura reported 
by Gimard, there were 3 deaths and 9 recoveries. Purpura simplex is 
rarely fatal; cases of purpura haemorrhagica usually recover unless 
marked febrile symptoms are present. The forms classed as typhoid, 



DISEASES OF THE LYMPH NODES. 

gangrenous, and purpura fulminans arc almost invariably fatal. The 
tendency to relaj in all varietii 

Treatment. The treatmeni of symptomatic purpura should have 
ace to t ho cause of the disease. The mild cases of primary pur- 
pura usually recover promptly under a tonic plan of treatment. The 
- - require confinement in bed, absolute quiet, and care to 
avoid exposure and even the slightest injury or extra pressure upon any 
part. Drugs do not seem greatly to influence the course of the disease. 
most frequently employed are supra-renal extract, hydrastis, 
hamamelis, aromatic sulphuric acid, the vegetable acids, ergot, and gal- 
lic- arid. Whether or not it is true, as claimed by some, that all hemor- 
rhagic diseases are related to scurvy, the striking improvement seen in 
this disease from the use of fresh fruit and vegetables suggests their 
employment in purpura. In some cases very decided benefit seems to 
follow their use in the acute stage, but more particularly in convales- 
cence. For hyperacute and gangrenous cases, little can be done except 
to treat the symptoms. Surgical means of arresting the haemorrhage 
are rarely successful. Iron and arsenic should be used during con- 
valescence. 



CHAPTER II. 

DISEASES OF THE LYMPH NODES [LYMPHATIC GLANDS). 

It is characteristic of infancy and childhood that the lymphoid tis- 
sues — tonsils, adenoids, external and internal lymph glands, and many 
smaller lymph nodules throughout the body — are prone to swelling and 
hyperplasia. While this tendency belongs to all children, in certain in- 
dividuals it is so marked as to deserve a place as a distinct diathesis. 
It was formerly classed as one of the manifestations of " scrofula " or 
" struma " ; but the proof that most of the manifestations once called 
are really forms of local tuberculosis, makes it undesirable 
to use that term to designate the condition under discussion. 

In robust children infectious processes of the nose, pharynx, or 
bronchi cause acute swelling of the lymph nodes in the neighbourhood, 
which rapidly subside when the cause is removed. In others, in whom 
ulnerability of the lymphoid tissm ■- . the hyperplasia in the 

lymph nodes i> out of proportion to the exciting cause and continues 
after the cause has ceased to operate. Certain children have at birth an 
jive development of Lymphoid tissue, particularly in the region of 
the throat in the form of enlarged tonsil-, adenoid vegetations of the 
pharynx, etc 

The influence of heredity in causing this condition is too often seen 



DISEASES OF THE LYMPH NODES. 831 

to be passed over as a coincidence. Frequently the parents, during child- 
hood, suffered from the same condition, and often every member of a 
large family of children is affected. They may be in other respects 
healthy, reared amid good surroundings, and show no evidence of any 
other constitutional disease. Any disease in the parents in consequence 
of which children are born with tissues having less than normal re- 
sistance, may be regarded in the light of a remote cause. 

The condition is seen to perfection in children reared in institutions 
and in crowded tenements. It is more common in cities than in the 
country. Anything which produces malnutrition or lowers the general 
vitality of the tissues may be ranked as a cause. Rickets is often asso- 
ciated; sometimes it is to be reckoned as a cause, and sometimes both 
conditions depend upon the same causes. 

During infancy, the lymphoid structures most frequently affected are 
those connected with the gastro-enteric and the bronchial mucous mem- 
branes; in later childhood it is those which are connected with the 
pharynx and tonsils. 

The degree of enlargement of the lymph nodes which is sometimes 
found in the different situations has often led to a misinterpretation of 
them, particularly by those who only seldom see autopsies upon infants or 
young children. They have often been connected with pathological condi- 
tions or clinical symptoms with which they have really nothing to do. 

Enlargement of the mesenteric glands and of the solitary follicles 
of the large and small intestine is very frequently seen in infants who 
have died from marasmus, and has been regarded as the cause of the 
wasting, while in reality it was only the consequence of the chronic 
intestinal indigestion which is an almost constant accompaniment of 
that condition. 

As age advances we usually see retrograde changes in the different 
groups of glands unless they become the seat of tuberculous infection. 
Those connected with the digestive tract generally begin to diminish 
after the second year, and by the fifth or sixth year the enlargement has 
almost disappeared; while the tonsils, adenoid growths of the pharynx, 
and enlarged cervical glands are usually stationary after the seventh or 
eighth year, and undergo quite a marked atrophy about the time of pu- 
berty. The presence of these enlarged lymph nodes and the catarrhal 
condition of the mucous membranes with which they are associated, are 
important in relation to all acute infectious diseases which affect these 
mucous membranes. They bring about an increased susceptibility to 
scarlet fever, measles, diphtheria, diarrhceal diseases, and most of all to 
tuberculosis. 

In the following table are given the situation and drainage areas of 
the various groups of lymph nodes of the head and neck which play so 
important a role in infancy and childhood. 



832 



DISEASES OF THE LYMPH NODES. 



10 



Kf Till 
'IT. 



Sub-occipi- 
tal. 
Mastoid. 



Parotid. 



Submaxil- 
lary. 

Supra- 
hyoid. 

Superficial 
cervical. 



Deep cervi- 
cal, upper 
set. 



Deep cervi- 
cal, lower 
set. 

Sub-hyoid. 



Retro-phar- 
yngeal 



NiMiini lnd Situation. 



One or two; al nape of neck. 

Four or five small ones; in 
mastoid region. 

Five to ten; on the surface 
and in the substance of 
the parotid gland. 

Twelve to fifteen; along base 
of jaw, beneath cervical 
fascia. 

One or two ; median line be- 
tween chin and hyoid 
bone. 

Five or more ; along external 
jugular vein, beneath pla- 
tysma, but superficial to 
the sterno-mastoid. 

Ten to sixteen; about bifur- 
cation of common carotid 
and along internal jugular 
vein. They are just above 
upper border of the thy- 
roid cartilage and on a 
level with the hyoid bone. 

A chain in the supra-clavicu- 
lar fossa. 



A few small glands below 
hyoid bone and near me- 
dian line. 

Two small glands in front of 
spine and upon preverte- 
bral muscles. 



Organs ob Areas prom which thkt 
Rkckiyk Lymph \ 



Scalp, posterior portion. 

Receive efferent vessels from group 1. 

and through them from part oi 

scalp. 
Scalp, frontal and parietal portions; 

orbit, posterior part of nasal fossa, 

upper jaw, posterior and upper 

part of pharynx. 
Mouth, lower lip, gums. 



Chin and middle portion of lower lip. 



Auricle, part of scalp, skin of face 
and neck, and some efferent ves- 
sels from groups 1 and 2. 

Lower part of pharynx, larynx, pal- 
ate, tonsils and part of tongue, 
part of nasal fossa, deep muscles of 
head and neck, and from inside the 
cranium. Receive also efferent 
vessels from groups 3 and 4. 

Connect with axillary group by a 
chain along axillary artery; also 
with glands of mediastinum and 
with groups 7 and 9. 

Communicate with group 8, and may 
connect below with chain of bron- 
chial glands. 

Pharynx and part of nasal fossa. 



STATUS LYMPHATICUS. 

This condition is known also by some writers as " lymphatism " ; 
while in its marked form it is quite distinct from that just described, the 
two conditions have many points of resemblance, have often been con- 
founded, and in fact shade into each other. The term " status lymphati- 
L8 applied to a very definite pathological condition which is asso- 
ciated with clinical manifestations, less constant and not characteristic. 
The relation between the lesions and the symptoms is little understood, 
and almost nothing is known of the etiology or pathogenesis. The most 
striking part of the lesion is the great enlargement of the thymus gland, 
with which is found a hyperplasia of the lymphoid tissues throughout the 
body, more marked than is seen in any other condition in childhood. The 
two most frequent symptoms are convulsions and attacks of asphyxia. 

The status lymphaticus is most often seen between the sixth and 
twelfth months, but may be met with in children of any age. Enlarge- 



STATUS LYMPHATICUS. 



833 



incut of the thymus to a degree sufficient to be regarded as pathological, is 

doI an infrequent condition. An association with rickets is often observed, 
but it is doubtful whether this is anything more than a coincidence. 

Since the large thymus is so important a lesion, it is desirable to 
know what may be regarded as normal. The most extensive observations 




Fig. 160. — Enlarged Thymus. The lungs, heart, and thymus are shown in the picture. 
The lungs have been turned back, showing the two lateral lobes of the thymus over- 
lapping the heart; the central lobe, above, covers the trachea. History. — Breast fed, 
male child, nine months old, well developed; ill less than twenty-four hours; dyspnoea, 
slight cyanosis, with death from asphyxia. T. 103° F. Autopsy.— Besides the large 
thymus there were present the general lesions of the status lymphaticus to a marked 
degree; lungs deeply congested. 



upon this point have been made by Bovaird and Nicoll, who weighed 
the thymus in 495 consecutive autopsies in children under five years. 
They found that the weight was greatest at birth, the average being 
7.7 grams. After this time the change in weight was very slight for 
the period of five years, the average for the entire 495 observations being 
5.9 grams, which was about the same as the average for each of the years 
taken separately. Excluding cases in which the organ was so large as to 
be considered abnormal (10 grams or over), the average weight at birth 
was 6.5 grams; during infancy and early childhood, 4 grams. The re- 
54 



834 nisi. ASKS OV THE LYMPH NODES. 

suits o( these observations do not differ essentially from those of Fried- 
leben, which have been so extensively misquoted. It may therefore be 
assumed that tin 4 average weight of the normal thymus at birth is from 
6 to 7 grants; from birth to five years, from 3 to 4 grams. Anything 
over 10 grams may be considered abnormal. 

In the status lymphaticus the thymus is often from fiye to ten times 
larger than normal. In tin 4 marked cases its weight is from 30 to 40 
grams: in the less marked eases from 10 to 20 grams. The appearance 
of the enlarged thymus is well shown in the accompanying illustra- 
tion (Fig. L60). A thymus of the size shown weighs about 45 grams, 
or H ounces. In this instance it was nearly as large as one of the lobes 
of the lung. In general appearance, the enlarged thymus is rather more 
vascular than normal, hut other than hyperplasia, shows no constant or 
essential changes, either by gross or microscopical examination. 

The lymph nodes of the tracheo-bronchial region are greatly enlarged, 
« if t en to the size of small cherries, and are found in great clusters. Those 
of the mesenteric region may be still larger. Peyers patches are very 
prominent, and the solitary follicles of the small intestine appear like 
mustard seeds upon the folds of the mucous membrane. Those of the 
colon are also very prominent. The lymphoid tissues about the pharynx 
and all the lymph nodes of the body are greatly hypertrophied. The 
spleen is usually enlarged, with prominent follicles. There are no other 
constant changes. Those present are usually accidental, depending upon 
the cause of death. 

Symptoms. — In very early infancy this is one of the explanations of 
sudden death occurring after slight causes, and in some cases without 
any apparent cause. 

Death may be attributed to overlying, to asphyxia from food, or to 
some other condition affecting respiration, or infants are simply found 
dead in their cribs. 

Even in those who live until they are several months, sometimes 
several years, old, there may be nothing in their condition to indicate 
the presence of the status lymphaticus until something acute occurs. 
This may be in the nature of a slight accident, a surgical operation 
of a trivia] character, the administration of an anaesthetic, or some acute 
-•-. frequently one affecting the respiratory tract. The symptoms 
associated with this condition are most frequently of a nervous char- 
acter, usually attacks of convulsions, or they affect the respiration, caus- 
ing paroxysms of dyspnoea, cyanosis, and even asphyxia. A frequent 
history is somewhat as follows: A child previously regarded as healthy, 
often well nourished and perhaps entirely breast fed, is taken with con- 
vulsion.- followed by high fever, preceding which there may have been 
some pulmonary symptoms suggesting a commencing broncho-pneu- 
monia. The convulsions recur at short intervals; the temperature re- 



STATUS LYMPHATICUS. 835 

mains steadily high; the signs in the lung are few and Dot proportionate 
to the other symptoms; and death occurs in from twelve to thirty-six 
hours often in convulsions. 

In other cases convulsions are absent and the prominent symptom 
is asphyxia, which conies in paroxysms and may he so complete as to 
lead to the suspicion of laryngeal obstruction. If intubation or trache- 
otomy is performed, no relief follows. The child may die in the first 
severe attack, which may be preceded for a few hours by moderate 
dyspnoea, or may come on almost without warning. It is more frequent, 
however, for the first attack to be less severe, the child perhaps being 
resuscitated with some effort, after which he may breathe almost as w r ell 
as usual. In a few hours the attack of asphyxia is repeated; after sev- 
eral of these, each one growing more severe, death occurs. In these 
cases the elevation of temperature is usually slight and may be wanting. 

Symptoms similar to the above but of less severity and resulting in 
recovery would suggest status lymphaticus, although the diagnosis can 
not be established. 

The cause of the symptoms is not definitely known. The asphyxia 
has been ascribed to pressure of the large thymus upon the lungs, the 
trachea, the pneumogastric nerves, or the auricles of the heart. Pres- 
sure would certainly seem to be one factor in the production of the 
dyspnoea. Further evidence in support of this is obtained by the relief 
afforded by an operation in which the anterior mediastinum is opened 
and the thymus raised and either fixed to the sternum or removed. This 
has been done in several instances with striking benefit. 

In other cases, although the thymus may be quite as large as in those 
just described, the evidences of obstructive dyspnoea are much less and 
may scarcely be noticed. 

There is another group of cases, perhaps the largest of all, in which 
there are no symptoms distinctly referable to the status lymphaticus, and 
yet this condition appears to be the factor which determines the fatal 
outcome of what was apparently an infection or an inflammation of only 
moderate severity. What is seen here is simply a greatly diminished re- 
sistance to disease. In these cases it is only the autopsy which reveals 
the explanation. 

Diagnosis. — The diagnosis of the status lymphaticus is very uncer- 
tain. In some cases of marked enlargement it is possible to make out 
the enlarged thymus by percussion, but this is always difficult on ac- 
count of its proximity to the lungs and trachea. AYe may suspect this 
condition during life; we can hardly do more. Marked enlargement 
of the tonsils and the adenoids exists so frequently without thymus en- 
largement, that this can hardly be regarded as suggesting the condition. 
The hyperplasia of the tracheo-bronchial or mesenteric lymph nodes or 
of the follicles of the intestine produces no especial symptoms. 



836 DISEASES OF THE LYMPH NODES. 

Prognosis. -While this condition apparently may exist for an in- 
definite time without producing any symptoms, it undoubtedly often 
determines a fatal outcome o\' what might otherwise have been a mild 
illness or a trivial accident. It is especially important in connection 
with acute bronchitis and broncho-pneumonia, with attacks of convul- 
sions, with the shock of slight operations, and with the administration of 
anaesthetics, particularly chloroform. It is one of the most frequent 
explanations of unexpected death from slight causes, such as an explor- 
atory puncture or the injection of antitoxine. 

At present no known treatment has any influence upon the condition. 

SIMPLE ACUTE ADENITIS. 

This is an acute inflammation of the lymph nodes which in infancy 
frequently terminates in suppuration. A certain amount of inflamma- 
tion of the lymph nodes occurs in children in all acute processes affect- 
ing the mucous membranes, especially when they are severe or prolonged. 
Those in connection with the various internal organs are considered with 
the diseases of the organs. Acute inflammation of the external nodes 
is of sufficient frequency to require separate consideration. While this is 
probably always secondary to some pathological process in the skin or 
mucous membranes, the primary condition may be so slight as to be 
overlooked, and the adenitis may be the more important condition or may 
even assume the appearance of a primary disease. It is particularly in 
infants that this is seen, and it depends upon the unusually active ab- 
sorption and upon the susceptibility of the lymphoid tissues at this age. 
The cervical glands are frequently affected, and occasionally those of the 
axillary and inguinal regions. 

Etiology. — Acute adenitis occurs in children of all ages in connection 
with diphtheria, scarlet fever, measles, and influenza. In such cases it 
is often severe, and after scarlet fever, frequently terminates in sup- 
puration. With the simple acute catarrhal processes of the pharynx 
and rhino-pharynx adenitis also occurs, but it is usually mild and rarely 
ends in suppuration. In infancy, on the other hand, acute adenitis 
from simple catarrh is not only very common but often severe, and 
frequently terminates in suppuration. Ulcerative stomatitis, carious 
teeth, eczema of the scalp or traumatism, may excite adenitis in chil- 
dren of all ages. Axillary adenitis may result from vaccination; ingui- 
nal adenitis, from vaginitis. 

Of 109 cases of acute adenitis from my records, not including any 
associated with diphtheria, measles, or scarlet fever, more than three- 
fourth- occurred in the first two years, and half of them in the first year 
of life. This susceptibility of infants is very striking. The disease 
occur- frequently in those who are in other respects perfectly healthy, 



SIMPLE ACUTE ADENITIS. 



837 



and often when the evidences of disease of the mucous membrane are 
slight. This is true not only of the cases of cervical adenitis, but also 
of others in which the inguinal glands are involved. The inflammation 
is excited iii most of these cases by the absorption of pyogenic germs, 

usually staphylococci or streptococci, from the mucous membranes or 
skin. 

Lesions. — The changes taking place in the glands are acute conges- 
tion, with swelling, oedema, and active hyperplasia of the lymphoid ele- 
ments. The process may terminate in resolution or in suppuration 
according to the intensity of the infection and the susceptibility of the 
tissues. When severe enough to cause suppuration, the adenitis is ac- 
companied by considerable inflammation of the surrounding cellular 
tissue. 

In the series of 109 acute cases to which I hare referred, not includ- 
ing the specific infectious diseases, 96 were cervical, 9 were inguinal, 
and 4 axillary; sixty-two per cent terminated in suppuration, the latter 
being nearly all in infancy. Suppurative otitis was present in sixteen 
per cent of the cases. Suppurative retro-pharyngeal adenitis (retro- 
pharyngeal abscess) was seen in several cases. 

In infancy the disease is usually unilateral, or, if bilateral, the 
glands of one side are more severely affected than those of the other. 
Suppuration is nearly always of one 
side, and usually the abscess starts 
in a single gland. 

Symptoms. — The symptoms and 
course of the adenitis of the specific 
infectious diseases belong to their 
clinical history. Suppuration is in- 
frequent, except after scarlet fever. 
It is very rare after diphtheria. 

The typical cases of acute ade- 
nitis are those which occur in in- 
fancy. There are present the symp- 
toms of the original disease — usually 
catarrh of the nose or rhino-pharynx, 
mouth, or ear, which may not be very 
severe, and sometimes is overlooked. 
The glands most frequently af- 
fected are the deep cervical group. 
The tumour appears just below the 
angle of the jaw at the anterior border of the sterno-mastoid muscle 
(Fig. 161). The swelling during the acute catarrh is not rapid or great. 
but continues after the original process has subsided until it reaches the 
size of a walnut or even larger. In the most acute cases there is marked 




Fig. 161. — Acute Suppurative Ade- 
nitis ix ax Infant Oxe Year Old. 
Showing the most frequent situation of 
the tumour in the cervical region. 



8 18 



DISEASES OF THE LYMPH NODES. 




Fig. 162. — Acute Suppurative Ade- 
nitis (inguinal) in an Infant Three 
Months Old. 



inflammation of the periglandular cellular tissue, with pain, tenderness, 
and extra heat. If suppuration occurs, it is generally evident in the 
latter part of the second week, hut sometimes it may be as late as the 

third or even the fourth week. In 
the axillary or inguinal region 
(Fig. 1(><?) the symptoms of ade- 
nitis are essentially the same as in 
the neck. In the inguinal cases 
the degree of catarrh of the mu- 
cous membrane is often very slight. 
Most cases run their course with 
slight fever and few general symp- 
toms ; but in young infants the 
constitutional symptoms are often 
severe and the physician may be in 
doubt whether the local process is 
sufficient to explain them. The 
temperature may be from 102° to 
10-t° F. for several days, witli con- 
siderable prostration, which is much 
increased if there is complicating 
otitis. After suppuration, if freely 
opened at the proper time, the abscess heals rapidly and permanently, a 
sinus being rare. Occasionally infection extends from one gland to an- 
other, and a succession of these glandular abscesses occurs. 

In the non-suppurative cases the swelling may be even greater than 
in those which suppurate; but it is less diffuse and apparently limited 
to the gland. It subsides slowly in the course of from four to eight 
weeks, often leaving a small tumour which may be apparent for several 
months. In susceptible children recurrent attacks of acute inflammation 
may lead to chronic enlargement which may last indefinitely. The?e 
glands do not become cheesy, except from subsequent tuberculous in- 
fection. 

The acute cases in infancy in which suppuration occurs, appear to 
recover about as promptly and quite as completely as those terminating 
in resolution, although in the former the constitutional symptoms are 
more severe. 

Diagnosis. — This is usually easy if it is remembered that, with the 
exception of the specific infectious diseases, and occasionally local causes 
like eczema of the scalp, carious teeth, etc., acute suppurative adenitis 
ntially a disease of infancy. I have often seen it mistaken for 
mump- when the swelling was severe, but on close examination there is 
but little resemblance between the conditions. The disease is usually 
acute, and has little in common with the slow suppuration seen in later 



SIMPLE CHRONIC ADENITIS. 839 

childhood from the breaking down of tuberculous glands. In the oc- 
casional cases seen in which the disease runs a slow course a diagnosis 
from the tuberculous form may be aided by a tuberculin test. 

Treatment. — Prophylaxis requires that in all acute catarrhs the mu- 
cous membrane should be kept as clean as possible by the use of nasal or 
pharyngeal sprays, or by syringing with simple solutions like Dobell's 
or Seiler's, or one of common salt. 

In the stage of acute inflammation very hot applications or an ice- 
bag may be used for the relief of pain. It is very doubtful whether 
either of these means has much influence in preventing suppuration. If 
abscess forms, incision should be deferred untii pointing has taken place. 
If this plan is followed, refilling is rare. A simple incision with proper 
aseptic treatment is all that is required. Curetting may be done if there 
is much broken-down tissue present, but it is not usually necessary. In 
most of the cases the abscess promptly heals and a perfect cure takes 
place. In cases which do not suppurate, absorption may be promoted 
by the internal use of the iodide of potassium in full doses — gr. x daily 
to an infant of one year. I confess rarely to have seen any benefit from 
painting with iodine or from inunctions of iodine ointment or the oleate 
of mercury. If adenitis is secondary to carious teeth, eczema, or ulcera- 
tive stomatitis, these conditions should receive appropriate treatment. 
Such cases do not usually suppurate, but subside rapidly when the 
primary cause is removed. 

SIMPLE CHRONIC ADENITIS. 

This consists in a simple hyperplasia of the lymph nodes. There are 
considered here only the external glands, but those of the cavities of the 
body are affected in a similar way, in diseases of the mucous membranes 
with which they are connected. 

Simple chronic adenitis is not nearly so frequent as the acute form 
even in infants and young children, and it is rare after the fifth year. 
It may follow one or more attacks of acute adenitis, or it may result from 
subacute or chronic inflammations of the skin or of the various mucous 
membranes, infection from which causes the acute form. The most fre- 
quent subjects are children who have the diathesis described as " lym- 
phatism." 

Symptoms. — The glands upon both sides of the neck are usually in- 
volved, and more often a group than a single gland. The degree of 
swelling is not generally great, being much less than in acute adenitis, 
and usually less than in the tuberculous form. There are no constitu- 
tional symptoms. Hypertrophy of the tonsils and adenoid growths of 
the pharynx are frequently present. There is no tendency to suppura- 
tion or caseation. The swelling usually increases slowly for one or two 
months, then remains stationary for about the same length of time, after 



g40 DISEASES OF THE LYMPH NODES. 

which it slowly subsides. A subacute course is more frequent Hum a very 
chronic one. 

Diagnosis. These cases are especially to be distinguished from those 
of tuberculous adenitis. The most important points for differentiation 
are, that they occur most frequently in children under two years, a 
period when tuberculous adenitis is not common; some definite exciting 
cause is usually present; caseation and suppuration do not occur; the 
glands do not become adherent to the skin or to the deeper tissues; they 
enlarge much more rapidly than do the non-caseating tuberculous glands; 
and they are influenced to a much greater degree by constitutional 
treatment. The children do not respond to tuberculin tests. 

Treatment. — Operative measures are not called for in simple ade- 
nitis; but there are some cases in which operation is to be considered 
if a thorough trial of other measures for two or three months has been 
without benefit. Local causes usually found in the pharynx, nose, or 
mouth should be removed if possible. Often more can be accomplished 
by removal to a climate in which the child's catarrhal symptoms are 
relieved than by all else. Little benefit is seen from local applications. 
The most useful internal remedies are, the syrup of the iodide of iron 
(twenty drops three times a day to a child of four years), and arsenic 
(two or three drops of Fowler's solution three times a day). Cod-liver 
oil should be given except during warm weather. 

SYPHILITIC ADENITIS. 

It is quite rare that a marked degree of glandular enlargement is 
seen as a symptom of hereditary syphilis; indeed, it is so rare that it is 
often forgotten that chronic multiple glandular enlargements are ever 
due to this disease. In the few examples that have come under my ob- 
servation, this has been a late symptom of hereditary syphilis. The 
glandular enlargements were cervical and multiple, and the degree of 
swelling was often marked. They may be associated with disease of the 
bones or of the mucous membrane of the throat or of the nose, or with- 
out signs of such disease. The diagnosis of syphilis rests upon the asso- 
ciation of other late manifestations of the disease — keratitis, periostitis, 
deformities of the teeth, the Wassermann reaction, and the prompt 
improvement under anti-syphilitic treatment. In their local appearance 
they resemble tuberculous glands. 

TUBERCULOUS ADENITIS. 
(Scrofula.) 

Tuberculous disease of the lymph glands of the cavities of the body 
is discussed elsewhere; only that of the external glands is here consid- 
ered. This condition presents some striking peculiarities: it is rela- 



TUBERCULOUS ADENITIS. 841 

lively rare in infancy, although a frequent form of tuberculosis in older 

children; it often exists as the only apparent tuberculous lesion in the 
body. In the great majority of cases it is the cervical glands which are 
affected. 

Etiology. — The age at which tuberculosis of the cervical lymph glands 
is usually seen is from three to ten years. In my experience with tuber- 
culosis in infancy, the external glands are rarely involved, while the 
bronchial glands are almost invariably the seat of infection. 

Local conditions favouring infection are adenoid growths of the 
pharynx, chronic pharyngitis, and hypertrophied tonsils; less frequently 
chronic otitis, chronic conjunctivitis, and pathological processes of the 
skin or the mouth, such as eczema of the face or scalp, ulcerative stoma- 
titis, carious teeth, etc. That the pharynx is the most frequent seat of 
primary infection, is shown by the fact that the deep cervical glands are 
generally first affected. The question often arises whether the process 
is. at first a simple one, and later becomes tuberculous, or whether it is 
tuberculous from the outset. My own belief is that in most cases the 
process is a tuberculous one from the beginning. 

Children who are by inheritance predisposed to tuberculosis and those 
also who are prone to glandular enlargements — two conditions which are 
by no means identical — are the ones most liable to be affected. Attacks 
of acute infectious diseases, particularly measles, scarlet fever, and influ- 
enza, frequently play the role of exciting causes. 

The age of those affected corresponds very closely with that at which 
children are most often seen with hypertrophied tonsils and adenoid 
growths of the pharynx. The subsidence of symptoms about the time of 
puberty, is also characteristic of both conditions. Of forty-five cases of 
tuberculous cervical adenitis in children studied by Park, twenty-five 
showed the human type of bacillus, and twenty the bovine type. This 
is in striking contrast with the results found by him in other forms 
of tuberculosis in children and points strongly to food infection as a 
cause. 

Lesions. — It has been already stated that in the great majority of 
cases the cervical lymph nodes are involved, and generally they are the 
only ones affected. In 155 cases of tuberculous glands in the series 
reported by Treves, those of the neck were the seat of disease in 145 and 
the only seat in 131 ; those of the axilla were involved in 17, but alone 
only in 4; the groin in 8, and alone in 6. The nodes first affected are 
most frequently the upper set of the deep cervical group; sometimes, 
however, it is the superficial nodes of the submaxillary, or the parotid 
group, and occasionally the submental or the pre-auricular. The chain 
of deep cervical nodes which is involved, follows the carotid artery, and 
often extends some distance below the clavicle. These deep nodes are 
sometimes connected with the bronchial group. 



842 DISEASES OF THE LYMPH NODES. 

The process in all tuberculous glands is essentially a chronic one, 
bul pathologically the cases may be divided into two groups, correspond- 
ing somewhat to the forms of disease Been in the lungs. In one group 
the process is more rapid, and tends to early caseation and softening; 
the products of inflammation are mainly cellular, and the amount of 
fibrous tissue 1 is small. In another group the course is slower, and fibrous 
tissue predominates, caseation and softening being infrequent. 

In the first group the glands in the early stage are swollen, of a pale 
pink colour, and homogeneous; later they become more firm, and show, 
as the first gross evidence of tuberculous deposits, small grayish-white 
Bpots, which are generally numerous and scattered through the affected 
gland; these spots enlarge, and may coalesce to form one large gray 
mass, involving nearly the whole gland. Subsequently there is caseation 
and then softening, usually beginning in the centre of the caseous area. 
Inflammation within the gland is followed by that of the surrounding 
tissues, which may result in adhesions or in the formation of a periglan- 
dular abscess. The first change in the gland is the production of epithe- 
lioid and giant cells, about which there is a zone of small round cells; 
cheesy degeneration then begins in the centre. The caseous masses may 
become encapsulated by the production about them of fibrous tissue; or 
softening may occur at one or more foci, and an abscess form. Such an 
abscess contains curdy material but very little true pus, the contents 
being chiefly detritus from the broken-down node. Tubercle bacilli are 
usually more numerous in the early stages of the process, but are often 
difficult of detection in broken-down tissues, and the curdy pus is some- 
times sterile. As the glands soften, the process gradually extends from 
the centre to the surface, and they become adherent to the surrounding 
structures — blood-vessels, nerves, or the fascia — they fuse together and 
form large knotty masses, and when they ultimately break down they 
lead to the formation of an abscess in the cellular tissue, finally involv- 
ing the skin. In the form of suppuration which occurs in and about 
tuberculous nodes, an important part is often played by other bacteria, 
usually the staphylococcus or the streptococcus. 

In the second group of cases, where the process goes forward more 
slowly, the changes are not quite the same, the essential difference being 
that the amount of fibrous tissue is much greater. These nodes are not 
so vascular; they are tougli and hard, appearing like small fibrous 
tumours. The capsules are greatly thickened, and under the microscope 
La seen fibrous tissue arranged in concentric layers, often inclosing small 
caseous masses. These nodes less frequently form adhesions to the sur- 
rounding 1 issues, and consequently are freely movable, while suppura- 
tion is quite exceptional. Although the separate tumours are much 
smaller than in the first group, the glandular mass is often a large one, 
because of the number of glands involved. 



TUBERCULOUS ADENITIS. 



843 



■ 



It is seldom in either group of cases that the process is Limited to a 
single node or even to two or three nodes. Very often an entire chain 
is involved (see Fig. 163). 

Tuberculous infection of the lymph nodes may terminate in resolu- 
tion, encapsulation, calcification, or suppuration. The inflammation 
may subside before caseation has taken place 
and the inflammatory products undergo ab- 
sorption. After caseation has occurred the 
masses may become encapsulated and contract 
to small fibrous nodules. Calcification of the 
glands in this location is rare. In other cases 
caseation is followed by breaking down, lique- 
faction, and an external abscess. The course 
which the local disease takes will depend upon 
the intensity of the infection and the general 
vigour and resistance of the child. There is 
seen in most cases a tendency of the inflam- 
mation to subside spontaneously about the 
time of puberty. Cure has sometimes followed 
an acute attack of intercurrent disease, such 
as erysipelas of the face, and even scarlet 
fever. 

Symptoms. — In the early part of the dis- 
ease there are no symptoms but the glandular 
swelling, and this begins very gradually. In 
most cases both sides are involved, but as the 
disease progresses the advanced changes are 
usually confined to one side. The enlarge- 
ment is seldom continuous; it often increases 
for a time and then remains stationary or 
even diminishes, to take a new start from 
the stimulus of some fresh infection of the 
mucous membrane with which the glands are 
associated, such as an attack of measles or 
influenza, or simply from a deterioration 
in the patient's general health. During ex- 
acerbations, the glands may be painful and 
tender, and show the usual signs of local in- 
flammation. 

The whole course of the disease varies from several months to as 
many years. Treves gives three and a half years as the average dura- 
tion when suppuration occurs. The glands first affected are usually 
those situated near the bifurcation of the common carotid artery. Such 
tumours usually make their appearance just in front of the sterno-mas- 



Fig. 163. — Posterior Cer- 
vical Chain of Tuber- 
culous Lymph Nodes. 
The upper one -showed 
giant cells and extensive 
cheesy degeneration; one 
at the middle showed 
early tuberculous changes 
— cell infiltration, giant 
cells, and a small area of 
cheesy degeneration; the 
lowest node showed one 
small tubercle with a 
cheesy centre. Child two 
and a half years old. 
(Dowd.) 



su nisi: asks of the lymph nodes. 

toid muscle — sometimes behind it— and at the level of the upper border 
o( the larynx or the hyoid bone. In the more rapid cases the tumours 
usually attain a considerable size in three or lour months, sometimes in 

half that time. The usual si/.e reached is from thai of an almond to an 
English walnut. At first the tumours are movable and preserve their 
distinct outline: later they become adherent, first to the deeper tissues 
and to each other, finally to the skin, and there is formed an irregular 
nodular mass in which it is sometimes difficult to make out the individ- 
ual glands. As the process approaches the surface there are small spots 
o( softening-; then there is distinct fluctuation; the skin becomes discol- 
oured and finally gives way, and there is a discharge of thick, curdy pus, 
which may continue for an indefinite time, until the whole of the broken- 
down gland has been thrown off. This course is repeated with each suc- 
cessive gland which breaks down. In cases progressing more slowdy the 
glands become adherent chiefly to one another, and suppuration is less 
frequent. 

In what proportion of tuberculous lymph nodes suppuration occurs, 
it is difficult to say. Like other tuberculous lesions in the body, this one 
is more frequent than was once supposed; and in the past most of those 
which did not break down were not classed as tuberculous. It is prob- 
able that of the cases allowed to run their course about one-half terminate 
in suppuration. Two forms of suppuration occur in connection with 
tuberculous glands — one an abscess of the gland proper, the other outside 
of and usually over it. In a typical case of the first variety, the gland 
is distinctly outlined and often superficial, there is very little inflam- 
mation, the spot of softening and fluctuation is small, and the pus dis- 
charged is always curdy. In the second variety the abscess is preceded 
by a more diffuse swelling, and the outline of the gland may not be made 
out; the signs of inflammation are more marked, the area of fluctuation 
is larger, and the pus is more like that of any ordinary abscess. Often 
the two varieties are combined ; as when a gland beneath the deep fascia 
breaks down and there is formed directly over it an abscess in the cellular 
tissue, which communicates through a narrow opening with the gland 
beneath. In such cases the sinus continues open for a ver} r long time, 
until the whole of the gland has been discharged. If healing occurs be- 
fore this, the cicatrix soon breaks down. 

When- abscesses are allowed to open spontaneously, large, irregular, 
and usually very intractable ulcers form. The skin is undermined for 
a considerable distance, and it has an unhealthy appearance. Such ulcers 
sometimes continue for many months in spite of all treatment, partic- 
ularly if the patient's general health is poor. The scars left after them 
are large and unsightly, and sometimes positively deforming (Fig. 1G4). 
Their appearance is quite characteristic. They often have many tabs of 
skin attached to them; they may form prominent ridges which undergo 



TUBEHCl LOIS ADKNITIS. 



845 



re of a purplish-red colour, and 

re often sensitive and painful. 



contraction like those after burns; they 
adherent to the deeper tissues. They 
As time passes they 
atrophv and become less 
conspicuous, though they 
remain throughout life. 

The general health of 
children with tuberculous 
glands may be much or 
little affected, and not a 
few remain in good con- 
dition throughout the 
whole course of the dis- 
ease, particularly when 
suppuration does not oc- 
cur, but sometimes even 
when it is protracted. 

Prognosis. — Tubercu- 
losis of the external 
lymph nodes is seldom 
if ever the direct cause 
of death; although the 
course is often very pro- 
tracted, ultimate recov- 
ery can usually be pre- 
dicted. As previously 
stated, it is surprising 

that this process is so frequently the only tuberculous lesion in the 
body. Treves states that the percentage of those who die from gen- 
eral tuberculosis is so small that this danger is not to be considered 
an argument for operation. Poore reports that of 58 cases treated by 
operation, only 2 were known to have died from tuberculosis. Dowd 
has collected reports of 309 cases treated by removal more or less com- 
plete, whose histories were followed for several years after operation. 
Of these, 202, or 65.4 per cent, were apparently cured ; 57, or 18.-1 per 
cent, were living, though suffering from either local or general tuber- 
culosis; 50, or 16.2 per cent, died of tuberculosis. These statistics surely 
do not support the hopeful views of the writers first quoted, but they are, 
I think, more in accord with general experience. 

Diagnosis. — The diagnostic features of tuberculous glands are the 
age of the patient — usually from three to ten years — the site of the pri- 
mary swelling, the indolent course, the trifling original cause, and the 
disposition to slow caseation, softening, and abscess. The tuberculin 
reaction is of great assistance. The cases of simple hyperplasia are 




Fig. 164. — Cicatrices Following a Neglected Case 
of Tuberculous Adenitis, in a Girl Seven Years 
Old. There is also a tuberculous patch upon the 
skin of the cheek in a very frequent location. 



846 DISEASES OF THE LYMPH NODES. 

usually in children under three years, their progress is much more rapid, 
there is often some definite cause, and in most cases they nearly or quite 
disappear in the course of three or four months. They suppurate, if at 

all, during the tirst mouth. Syphilitic disease is to be recognised mainly 
by discovering the evidence of syphilis elsewhere, and by the effect of 
treatment. In Eodgkin's disease, glandular groups in other parts of 
the body are involved simultaneously or in rapid succession. There are 
uo Bigns of inflammation or caseation; and the swellings are accompanied 
by very marked and definite constitutional symptoms — anaemia, emacia- 
tion, and general prostration. Malignant growths are very rare; they 
increase rapidly, often attaining a great size in a few months. 

Treatment. — The general treatment of tuberculous glands is to put 
the child under the very best surroundings possible. The seaside has a 
great reputation for such cases, and no doubt the majority do very well 
there; but some are benefited even more by a dry, mountain climate. 
At all events, a child from the city should be sent into the country 
whenever this is possible. Internally the only remedies which have any 
special virtues are cod-liver oil and the syrup -of the iodide of iron. The 
latter should be given in full doses, i. e., twenty or thirty drops, three 
times a day, to a child of six years. Arsenic and iron are useful as gen- 
eral tonics. Local applications are of little value and most of them posi- 
tively harmful ; painting with iodine and poulticing should be discarded 
altogether. The parts should be rubbed or handled as little as possible. 

It is important in every case to remove from the nose and throat all 
sources of local irritation. Hypertrophied tonsils and adenoid tissue of 
the pharynx should receive attention, also any pathological conditions in 
the nose, such as hypertrophy of the turbinated bodies, and chronic otitis, 
chronic conjunctivitis, carious teeth or ulcers in the mouth. All these, 
if they do no more, keep up a constant glandular irritation, and produce 
conditions which are most favourable for the activity of the tubercle 
bacillus. 

Operative Measures. — These are indicated if, after two or three 
months of constitutional treatment, the glands affected continue to in- 
crease in size and number, or if softening occurs. The advantages of 
operation over leaving the case to Nature are, that it leaves a clean scar 
instead of a large, irregular one; that it shortens the disease and pre- 
vents the long, tedious suppuration of cases left to themselves; that it 
is a radical measure; and that it avoids the danger of general infection 
by removing the tuberculous focus. 

The best results follow operation when it is done early before the skin 
is involved or the glands have; softened or have formed extensive adhe- 
sions to the great, vessels and neighbouring structures; also where a 
chain of glands is involved and where the inflammatory process is slow 
or indolent, ii' performed early a thorough operation by a good surgeon 



HODGKIN'S DISEASE. 847 

in the majority of cases will result in a permanent cure. However, the 
operation is not contraindicated in cases which have gone on to a later 
stage, although the results may not be quite so satisfactory. 

Glandular ahscesses should in all cases be opened as soon as pus 
forms, to prevent the extensive undermining of the skin, which is so 
likely to occur. The opening should be a small one, and all squeezing of 
the gland or surrounding tissues avoided. 



HODGKIN'S DISEASE. 

(Pseudo-Leukcemia.) 

This is a rare disease in which there is a general hyperplasia of the 
lymphatic glands throughout the body, with growths of lymphoid tissue 
in the spleen, liver, and other internal organs. It is accompanied by 
marked anaemia, is progressive in its course, and usually terminates 
fatally. The cause is unknown. It is much more common in males than 
in females. Its occurrence in childhood is exceedingly rare. 

The chief lesion is in the lymph nodes which become greatly en- 
larged, and besides new ones develop during the course of the disease. 
The spleen is usually, the liver less frequently, involved and somewhat 
enlarged by the formation of lymphomatous masses which may also 
infiltrate almost any tissue of the body. Microscopically, the early 
changes in the glands consist in an increase in the lymphoid tissue. 
Later there is proliferation of the endothelioid cells, the formation of 
giant cells, and an overgrowth of connective tissue. The eosinophile 
cells are frequently present in the tissues in great numbers. Any of the 
external or internal groups of lymph glands may be affected, and in 
severe cases the disease may involve almost every chain of glands in the 
body. Of the external groups, the cervical and the axillary are usually 
most affected; of the internal groups, those of the mediastinum and the 
retro-peritoneal region. 

The disease develops very gradually, often insidiously. The external 
glandular swellings are usually the first noticed, but sometimes it is 
the anaemia which first attracts attention; occasionally it is the local 
symptoms resulting from the pressure of internal glands, which may 
give rise to oedema, pain, cough, or dyspnoea. The progress is generally 
slow but steady, and the glands may reach an immense size. The blood 
changes are inconstant. As a rule, there is a relative increase in the 
lymphocytes, while the total number of white cells is generally less than 
normal, although sometimes increased. 

Treatment is very unsatisfactory. Arsenic in full doses appears to 
benefit some patients. The use of the X-ray has produced striking, 
though in most cases only temporary improvement in the external glands. 



848 DISEASES OF THE SPLEEN. 

CHAPTER IIT. 

DISEASES OF THE SPLEEN. 

Weight. — From 140 observations made at the New York Infant 
Asylum the following were the weights recorded at the different ages: 

Weight of the Spleen in Infancy and Early Childhood. 



Age. 



Birth 

Three months . 
Twelve months 
Two years . . . . 
Three years . . . 



Ounces. 


Grammes. 


H 


7.7 


l A 


15.5 


% 


23.2 


1M 


38.5 


M 


46.4 



Position and Methods of Examination. — The normal position of the 
spleen is close against the diaphragm, its external surface being opposite 
the ninth, tenth, and eleventh ribs. Its anterior border comes as far 
forward as the middle axillary line, its posterior border being usually 
near the vertebral column. In infancy it is practically impossible to 
outline the spleen by percussion, unless it is enlarged. During full in- 
spiration the spleen is often depressed enough to be felt at the free border 
of the ribs, but at other times it can not be felt unless it is enlarged or 
pushed downward by some pathological condition in the chest. Nor- 
mal h', the long axis of the spleen is nearly parallel with the ribs, but 
when the organ is much enlarged, its axis corresponds nearly with a line 
drawn from the axillary line at the border of the ribs to the middle of 
Poupart's ligament. 

The thin abdominal walls of young children render palpation of the 
spleen much easier than in adults; and this is a much more satisfactory 
method of examination than is percussion. For satisfactory palpation 
it is necessary that the abdominal walls should not be tense. The child 
should lie upon his back with the thighs flexed and the skin, of course, 
bared. The physician, always having taken the trouble to warm his 
hands, should stand upon the left side of the patient and make pressure 
with the tips of the fingers, which are semi-flexed. The pressure should 
be at first light, and gradually increased, the fingers being then held 
stationary during two or three respirator}' movements. Under ordinary 
conditions the spleen can easily be felt when it is sufficiently enlarged 
to be of any diagnostic importance. 

When moderately enlarged, the lower border of the spleen is an inch 
or bo below the free border of the ribs; when greatly enlarged, it forms 
a tumour which may nearly fill the left half of the abdomen. 'A tumour 



ENLARGEMENT OF THE SPLE] 849 

in the left hypochondriac region is recognised to be the spleen, by the 

fact that it is freely movable laterally and at its lower border or ex- 
tremity, while it is attached above \ also its inner border can usually 
be felt to be thin and sharp, and marked about its middle by quite a 
deep notch. 

ENLARGEMENT OF THE SPLEEX. 

In Acute Disease. — The spleen is most frequently and most constantly 
enlarged in malarial and typhoid fevers, but it is occasionally bo in all 
the acute infectious diseases. 

In most of these cases the enlargement is chiefly from congestion, hut 
there may be acute hyperplasia and an increase in size of the Malpighian 
bodies. It may contain small haemorrhages, and in extremely rare cases 
the spleen may rupture. It is generally dark-coloured, soft, and some- 
what friable. In the cases which recover, the splenic swelling subsides 
with the original disease. 

In Chronic Disease. — Like the lymph nodes, the spleen is much more 
often enlarged in children, particularly young children, than in adults. 
Enlargement is seen at times in almost all the chronic diseases of early 
life; but it occurs most frequently in rickets, syphilis, malaria, tuber- 
culosis, the blood diseases, and in amyloid degeneration. Besides, it may 
be the seat of a primary growth, either benign or malignant. 

Rickets. — The splenic enlargement which accompanies rickets is gen- 
erally seen during the first year ; at this period it is very frequent. The 
swelling is usually moderate, but occasionally it is so great that the 
lower border is three or four inches below the ribs. 

Syphilis. — Enlargement of the spleen is one of the most constant 
lesions of hereditary syphilis. It is present with great uniformity in 
children born with syphilitic lesions, and very frequently during the 
active period of the disease in early infancy. It is seen at a later period 
during infancy or childhood, associated with other late symptoms. 

Malaria. — The swelling in cases of chronic malaria may be very great. 
The liver is not so often enlarged as in syphilis. 

Tuberculosis. — It is rare to find anything more than a moderate 
swelling of the spleen in tuberculosis. In the most acute cases this 
may be due to the fever and general infection; in those which are le<s 
rapid, it depends either upon tuberculous deposits or passive congestion 
from venous obstruction. 

The Blood Diseases. — Marked enlargement of the spleen is found in 
many cases of simple anaemia accompanied by moderate leucocytosis. 
The spleen is constantly swollen, and usually greatly so. in the pseudo- 
leukaemic anaemia of infants, in leukaemia, and in Uodgkin's disease. 
In the last two diseases the liver is also enlarged, but to a much less 
degree than the spleen; in the others it is but slightly changed. 
55 



850 DISEASES OF THE HONKS AND JOINTS. 

Amyloid Degeneration. — The spleen is constantly involved in amyloid 
disease, and the enlargemenl o( this organ, as well as that of the liver, 
may be very great. 

Cardiac Disease. — In all forms of cardiac disease, and in other con- 
ditions in which there is obstruction to the systemic venous circulation, 
the spleen is enlarged. It is scon in congenital as well as in acquired 
cases. 'The liver is usually enlarged, and there may also be dropsy of 
the feet. 

New-growths j Tumours, etc. — It is seldom in early life that the 
spleen is the scat of new-growths; these are usually varieties of sarcoma, 
hut carcinoma has also been reported. 

Primary Spleno-megaly. — The rare cases of immense primary en- 
largement of the spleen have been variously interpreted. By some 
writers the condition has been regarded as lymphoma. Bovaird x has re- 
ported two cases in children, sisters, one of which -was carefully studied 
microscopically, and the conclusions reached that the process was an 
endothelial hyperplasia. The condition was first described by Gaucher. 
Clinically the disease is characterised by a slowly progressing enlarge- 
ment of the spleen, which begins in early childhood and may continue 
for from live to twenty years; the size attained is very great, it often 
nearly tilling the abdomen. In one of Bovaird's cases the weight was 
twelve and a half pounds. The other s}mrptoms are a simple anasmia, 
inflammation of the gums with haemorrhages from the nose, gums, and 
sometimes beneath the skin, and finally secondary symptoms due to the 
abdominal tumour. The course is very chronic, and thus far no known 
treatment has been of anv avail. 



CHAPTER IV. 
DISEASES OF THE BONES AND JOINTS. 

ACUTE ARTHRITIS OF INFANTS. 

The terms acute purulent synovitis, acute epiphysitis, pycemia of 
bone, and acute osteomyelitis, have all been applied to this condition. 
The disease is really a form of pyaemia. The causes and lesions may 
differ considerably in the different cases, but clinically they all have cer- 
tain features in common, viz., an acute joint inflammation with sup- 
puration. 

The acute arthritis of infants is essentially a disease of the first year, 
and is much more frequently seen in the first six months. The inflam- 
mation may begin in the joint, at the epiphyseal junction, or in the 

1 American Journal of the Medical Sciences, October, 1900. 



ACUTE ARTHRITIS OF [NFANTS. 851 

medullary canal; but, however ii may start, the joint is soon invaded. 
The nature of the arthritis varies somewhat with the exciting cause. 
When it is due to the gonococcus, it is usually confined to the joint : there 
is in most cases a superficial inflammation involving the synovial mem- 
brane, but rarely leading to destructive changes in the cartilage, liga- 
ments, or bone. When it is due to the streptococcus or staphylococcus, 
it may begin elsewhere than in the joint, which, however, is usually soon 
involved, and complete disorganisation may follow. It may also resull 
in a diffuse osteomyelitis, in a subperiosteal abscess, or a separation of the 
epiphysis. As a late result there may be a pathological dislocation or a 
" flail joint " ; less frequently there is ankylosis. 

Etiology. — The cause of acute arthritis in infants is the entrance 
of pyogenic organisms into the circulation. In my experience the or- 
ganism most frequently found is the gonococcus; next to this the strep- 
tococcus and staphylococcus; occasionally the pneuniococcus. and very 
rarely the influenza bacillus. In most cases occurring during the first 
two months of life, the portal of entry is probably the umbilical cord. 
Less frequently infection takes place through the skin, conjunctiva, 
genital tract, or the mouth. In the cases developing later it is oft en 
difficult to determine the point of entry, especially when the cause is the 
gonococcus. During the last few years 26 cases of acute gonococcus 
arthritis have been observed in the Babies' Hospital, only 2 of which, 
occurring during the first month, could be classed as infections of the 
newly born. The cases were observed during a hospital epidemic of 
gonococcus vaginitis, and yet 19 were in male children, in no one of 
whom was there any genital lesion, and in only one was there conjunc- 
tivitis. Of the 7 cases occurring in girls, only 2 had vaginitis. The 
portal of entry in these cases could not be definitely determined. 

Symptoms. — General symptoms often precede the .local ones. In the 
most acute cases the temperature is high and widely fluctuating, accom- 
panied by other symptoms of a severe infection. The earliest local 
symptoms are pain and tenderness, soon followed by swelling, which may 
deVelop quite rapidly in a single joint, or in several joints simultane- 
ously. In those superficially situated there is redness of the skin, and 
fluctuation may be evident in three or four days. In cases coming on 
more gradually the temperature may be only Prom 100° to L02° P., and 
suppuration may not occur for two or three weeks. In the most severe 
cases the progress is rapid, one joint after another being involved, with 
general symptoms of pyaemia, and death may occur in a week or ten days, 
usually from some visceral inflammation, pneumonia, pericarditis, or 
meningitis. This very severe course is less frequent than the more pro- 
tracted one where symptoms last from two to four weeks. Unless the 
pus is evacuated, extensive burrowing may take place. 

In Townsend's collection of 73 cases, the joints were involved in the 



852 DISEASES OF THE HONKS AM) JOINTS. 

following order: Hip, in 38; knee, in 87; shoulder, in 12; wrist, in 5; 
ankle, in I : elbow, in 1 ; small joints, in 1. In throe- fourths of those 
rases only a single joint was affected. In my own 2(5 gonococcuB eases, 
the localisation was as follows: Finger or metacarpus, in 530 ; ankle, in 
IS; knee, in 1*3 ; wrist, in 12; too or metatarsus, in 10; shoulder, in 9 
elbow, in 5; temporo-maxillary, in 1; hip, in 1. The average number o 
joints involved was 1 or 5, the largest number being 8. The tendency of 
the gonococcus infections to involve the small joints is striking. 

Diagnosis. When several joints are involved, the disease is often 
mistaken for rheumatism, which, however, at this age is so rare that 
it may be ignored. Syphilitic epiphysitis resembles it in the localised ten- 
derness and disability; but the rapid swelling and the severe constitu- 
tional symptoms are lacking. 

Treatment. — Cold applications or wet dressings may be useful in 
relieving the symptoms. In some eases, most frequently when the cause 
is the gonococcus, the inflammation subsides without suppuration. In 
infections due to other organisms, suppuration almost invariably occurs 
and early free incision should be practised, followed by fixation of the 
joint. The results depend in no small degree upon the promptness with 
which the pus is evacuated. In the gonococcus cases there may be com- 
plete recovery. In most of the others the functions are impaired. 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS. 

The chronic forms of tuberculous bone disease, on account of their 
insidious onset and the frequency with which they simulate other dis- 
eases, more frequently fall, in the early stage at least, into the hands of 
the physician than into those of the general or orthopaedic surgeon. All 
that will be attempted in this chapter will be to outline in a general 
way the most important forms — viz., disease of the vertebras, hip, and 
knee — dwelling particularly upon the early symptoms and diagnosis. 
For their fuller discussion, particularly as to the details of treatment, 
the reader is referred to text-books on general or orthopaedic surgery. 
The causes are the same, and the lesions are very similar in all forms, 
and will therefore be considered together. 

Etiology. — The age at which tuberculosis of the bones most fre- 
quently begins, is from the third to the eighth year, it heing compara- 
tively rare before the end of the second year. The sexes are affected 
with about equal frequency. Tuberculous bone disease may occur in a 
child who has previously been in apparent health, but more often in one 
who has been reduced by some previous illness, especially the infectious 
diseases; of these, it most frequently follows measles and whooping- 
cough. Of sixteen cases investigated by Park, the bacillus was of the 
human type in every instance. 



TUBERCULOUS DISEASE. 853 

A family history of tuberculosis is presenl in a large Dumber, hut 
by no means in a majority, of the cases. Like tuberculosis of the 
vical glands, it is rarely preceded by other tuberculous processes, al- 
though it may he followed by them. It usually appears as an example 
of primary infection; but it seems very improbable thai such should 
actually he the ease. It is more likely that there has previously been a 
latent focus of tuberculosis elsewhere in the body. In many cases dis- 
ease of the bronchial glands has been demonstrated by autopsy. Infec- 
tion from these or. from other tuberculous lymph glands is the most 
probable explanation of the origin of infection in cases of bone disease. 

Traumatism is often an exciting cause, and it may determine the 
site of the disease. 

Lesions. — The tuberculous joint diseases of childhood are, as a rule, 
secondary to disease of the bones. Hip-joint disease usually begins in 
the head of the femur, and knee-joint disease in one of the condyles; 
ankle-joint disease in the lower epiphysis of the tibia, etc. 

The frequency with which disease is seen in the different locations is 
shown by the following table, which gives the number of cases of each 
form applying for treatment at the Hospital for Ruptured and Crip- 
pled, New York, during ten years : 

Spine 2,145 cases, or 37.5 per cent. 

Hip 1,937 " " 34.0 " " 

Knee 1,222 " " 21.5 " " 

Ankle or tarsus 255 " " 4.5" 

Elbow 71 " " 1.2 " " 

Wrist 50 " " 0.9 " " 

Shoulder 24 " " 0.4 " " 

Total 5,704 100.0 

The character of the bone disease upon which chronic joint disease 
depends is generally a primary ostitis, which affects the articular ex- 
tremities of the long bones, usually beginning near the epiphyseal line; 
in the short bones it is a central ostitis. The stages in the process are. 
first, congestion, swelling, and cell infiltration, followed by caseation, 
and frequently by softening and suppuration. In the early stage, the 
bone is slightly enlarged, and on section one or more yellowish foci of 
disease are seen. The disease may be arrested in this stage, encapsula- 
tion of the inflammatory products taking place ; or it may continue until 
there is a more or less extensive breaking down or disintegration of the 
affected bone. As the disease extends there are involved the periosteum, 
the articular cartilage, and finally the joint itself. Abscess may form in 
the joint or in the soft parts surrounding the bone. The process is quite 
analogous to tuberculous disease of the lung. As the disease advances 
ligamentous attachments are loosened, and displacement of the parts 



854 DISEASES OV THE BONES AND JOINTS. 

occurs with the production o\' deformity, duo partly to muscular eon- 
traction and partly to the weight of the body. The inflammatory 
process, with its resulting disintegration, generally goes on to a certain 
point, where it is arrested. Gradually the broken-down bone substance 
is separated and thrown off in small particles in the discharge, and a 
reparative process begins, with the formation of healthy bone. Where 
joint structures have been destroyed, cure takes place by bony ankylosis. 
Sometimes the disease finds its way to the surface without involving the 
joint; at other times the disease may be arrested, and its products be- 
come encapsulated within the bone. Inflammation of the joint may 
occur by a gradual extension of the inflammatory process, or by a sud- 
den perforation of the articular lamella. As a result of extensive dis- 
ease, all the joint structures may be affected — the synovial membrane, 
ligaments, articular cartilages, and the cellular tissue surrounding the 
joint. The process of disintegration and that of -repair are both very 
chronic and measured by months or years. The entire course of the 
disease is from one to ten years, three years being about the average dura- 
tion. In the great proportion of cases but one joint is involved, although 
it is not infrequent in hospitals to see two, three, and sometimes four of 
the large joints affected in the same patient. 

Secondary Lesions. — Abscesses form in a considerable proportion of 
the cases, and often burrow a long distance before they reach the surface. 
Amyloid degeneration of the liver, spleen, and kidney, and sometimes of 
the intestines, occurs as the result of the prolonged suppuration, chiefly 
in connection with disease of the hip or spine, occasionally with that of 
the knee. General or localised tuberculosis, particularly tuberculous 
meningitis, may develop at any time and prove fatal. 

Caries of the Spine — Pott's Disease. 

This consists in a tuberculous inflammation of the bodies of the ver- 
tebrae, usually beginning in the central portion and extending to the 
periosteum, ligaments, cartilages, and, in fact, to all the contiguous 
structures. Secondarily it involves the membranes of the cord, the 
roots of the spinal nerves, and even the cord itself. The number of ver- 
tebra: usually affected is from two to Ave. The gross appearance of the 
lesion in a well-marked case is shown in the accompanying cut (Fig. 
165). After the bodies of the vertebrae have become softened and par- 
tially broken down by disease, the pressure from the superincumbent 
weight of the body causes them to fall together and produces a back- 
ward displacement of the spinous processes, giving rise to the deformity 
known as kyphosis, which in its extreme form is popularly known as 
"hunchback." 

Any part of the vertebral column may be affected; but the disease 
is most frequent in the dorsal region, as shown by the following statistics 



CARIES OF THE SPINE. 



855 




from the Hospital for Ruptured and Crippled: Of 2,143 cases, 72.5 
per cent affected the dorsal region, 15.3 per cent the lumbar region, 
and 12.2 per cent the cervical region. 

Symptoms. — The onset is gradual, often 
insidious, and the early symptoms are fre- 
quently overlooked or misinterpreted. The 
case may go on for weeks or even months 
before the true nature of the disease is rec- 
ognised, which is often not until deformity 
has occurred. In nearly all cases, however, 
the early symptoms are sufficiently char- 
acteristic to enable a careful observer to make 
a diagnosis before the stage of deformity. 

The most constant early symptoms are: 
(1) Pains caused by the irritation of the 
nerve roots and referred to various parts of 
the body, following the distribution of the 
spinal nerves ; ( 2 ) rigidity of the spine from 
muscular spasm, this being an attempt to 
prevent motion at the seat of disease; and 
(3) the assumption of various postures cal- 
culated to relieve pressure upon the diseased 
vertebral bodies. Sometimes the first symp- 
toms are those of pressure-paralysis; at oth- 
ers they are the local signs of abscess. In 
addition to the local symptoms mentioned, 
there is usually disturbed sleep, often ac- 
companied by moaning. 

Cervical Disease. — The pains are often felt above the point of dis- 
ease, frequently in the form of occipital neuralgia; sometimes they are 
referred to the front ur the side of the neck. They may be so frequent 
and so severe that the face assumes a constant expression of anxiety or 
distress. In other cases pain is excited only by an attempt at movement. 
The muscular spasm most frequently takes the form of slight torticollis, 
sometimes of slight opisthotonus; sometimes there is simply a fixation 
of the head by a tonic spasm of all the muscles of the neck ; both active 
and passive motion is resisted, and any movement may be so painful 
that the child involuntarily steadies his head with his hands. These 
symptoms come on gradually and are persistent. Sometimes they are 
overlooked, and the first thing to attract attention is a progressive weak- 
ness in the lower extremities, which proves to he the beginning of par- 
aplegia. Occasionally the first marked symptoms are those due to the 
formation of a retro-pharyngeaJ or a retroesophageal abscess. 

The deformity from cervical disease develops much later than when 



Fig. 165. — Pott's Disease of 
the Uppek Dorsal Region. 
A vertical section of the 
spine, showing disintegration 
of the bodies of the vertebrae 
and encroachment upon the 
spinal canal. (From a pa- 
tient dying in the Hospital 
for Ruptured and Crippled.) 



856 DISEASES OF T11K BONKS AND JOINTS. 

the disease is Located elsewhere. Usually the neck appears broadened or 
thickened in a nearly uniform way, and often the head seems to have 
settled downward upon the shoulders. In the lower cervical region a 
kyphosis is not infrequent : but in tin 1 middle and upper regions there is 
more often an anterior prominence, which may be fell in the posterior 
wall o\' the pharynx. 

Dorsal Disease. — The referred pains are now below the seat of dis- 
ease, and take the form of intercostal neuralgia or pain in the epigas- 
trium or the abdomen. They are often ascribed to cold, malaria, indi- 
gestion, or worms. There is a disposition to assume the prone position 
while sleeping, and also to lean across a chair or the lap of the nurse. 
The child walks carefully, holding the spine erect and very stiffly, and 
exhibits great caution in getting into or cut of bed, or in rising from a 
recumbent position. In the beginning there may be a slight lordosis, or 
forward curve at the seat of disease, instead of the usual kyphosis or 
backward projection, but the latter soon takes its place, and with it is 
seen the compensatory lordosis in the lumbar region. 

Lumbar Disease. — The first symptoms here are- of ten pain and lame- 
ness, referred to one of the lower extremities. This frequently leads to 
the suspicion that the hip is the seat of disease. In addition to the 
lameness there may be a tilting of the pelvis to one side, and sometimes 
(piite a distinct lateral curvature of the spine. Referred pains are not 
so frequent nor so severe as when the upper part of the spine is affected; 
they may be felt in the groin, in the loin, in the thigh, in the buttock, or 
in the hypogastrium. The gait and attitude are very characteristic: 
Throwing the shoulders well back, the patient walks stiffly, with short 
steps, holding the spine with the greatest care. He rises from the floor 
awkwardly and with difficulty. Deformity is not usually so early or so 
marked as when the disease is dorsal, and often before it is visible there 
are symptoms due to the formation of psoas abscess — lameness, flexion 
of one thigh, and a tumour deep in the iliac fossa or at the upper and 
inner aspect of the thigh; in both locations it has often been mistaken 
for hernia. 

Physical Era mi nation . — Whenever any of the above symptoms are 
present, the child should be stripped and submitted to a thorough ex- 
amination, the purpose of which should be to determine, first, the 
existence of any deformity: secondly, the mobility of the spine; thirdly, 
the presence of any secondary lesions, such as abscesses or paralysis. 
The mobility of the spine is best determined by studying the attitude, 
gait, and posture of the child, and the manner of stooping or rising 
from the floor. The gait has already been described with the symptoms 
of Lumbar disease. As it has been aptly put, "the child walks with his 
legs, but not with bis back.* 7 In stooping, the same disinclination to bend 
or move the spine is seen. It is often impossible to induce the child to 



CARIES OF THE SPINE. 857 

stoop at all, and when he dot's so, to pick up sonic object, there is acute 
flexion at the knee and hip, but as little bending of the spine as pos- 
sible. In rising from the recumbent position the same thing i> seen. 
The posture and attitude of the child will be modified by the position 
of the disease, and somewhat by the activity of the process at the time; 
however, by comparing the movements referred to with those of a 
healthy child, the great difference will at once be apparent. If the 
symptoms point to cervical disease, a digital exploration of the pharynx 
for deformity or abscess should be made, and the extremities should 
be examined for paralysis. If the disease is in the lumbar region, 
deep palpation of the iliac fossa should be made to discover a psoas 
abscess, and the passive movements of the thigh should be carefully 
tested to determine whether there is any resistance to extreme exten- 
sion, this often being present before the psoas, tumour. Xo matter how 
clearly the lameness may be at the hip, it should be remembered that 
this often results from disease of the lumbar spine. If the thigh is flexed 
and freely movable except in extension, the symptoms are probably the 
result of psoas irritation, for in hip- joint disease the other movements 
of the joint are also resisted. 

The deformity of Pott's disease is often spoken of as " angular " cur- 
vature of the spine. While this is a true description of the disease at 
an advanced stage, there is often in the early stage only a general curve. 
Later a slight knuckle is seen from the unnatural projection of a single 
spinous process. This deformity may increase and finally involve five or 
six vertebrae. It is usually greatest in the upper dorsal region. A slight 
prominence, which does not disappear on suspending the patient, is al- 
ways suspicious. 

Tenderness upon pressure over the spinous processes and increased 
sensitiveness to heat and cold are rarely present. Pain may sometimes 
be produced by downward pressure upon the head or shoulders in the 
axis of the spine. This symptom is not necessary for diagnosis, and the 
attempt to elicit it is strongly condemned by Gibney, who has seen seri- 
ous harm follow such a test. 

Course of the Disease. — Caries of the spine is a very chronic disease, 
its course being measured by months or years, but marked, as in all 
chronic diseases, by periods of remission and exacerbation. An exacer- 
bation may follow traumatism, and is often accompanied by the forma- 
tion of an abscess. After the disease has lasted from one to three years, 
the destructive inflammation usually ceases and repair begins, a cure 
being finally effected by a process of consolidation of the fragments 
of the diseased vertebra 1 , and the production of ankylosis. Relapses 
are easily excited by traumatism, by improper treatment, or by dis- 
continuing the use of mechanical supports before the disease is ar- 
rested. 



g58 DISEASES OF THE BONES AM) .JOINTS. 

Abscesses. — The frequency with which abscesses occur depends some- 
what upon the treatment. Townsend states that of ."ISO cases, abscess 
was present in twenty per cent. They are rarely seen earlier than three 
or four months from the beginning of symptoms, and usually belong to 
the Becond year of the disease. They sometimes form with acute symp- 
toms, hut more frequently they appear as typical cold abscesses. Those 
connected with cervical disease are retro-pharyngeal or rein oesophageal, 
or they may open externally, usually just above the clavicle, in front of 
the sterno-mastoid muscle. Those with disease of the lower cervical 
and upper dorsal vertebrae are apt to burrow along the spine, appearing 
in the lumbar region : rarely they may rupture into the oesophagus or 
the pleura] cavity. Those with disease of the lower dorsal or lumbar 
vertebra 1 may open just above the iliac crest posteriorly, or burrow an- 
teriorly between the abdominal muscles, but the usual course is for them 
to follow the psoas muscle, appearing in the groin just above Poupart's 
ligament or at the upper and inner aspect of the thigh. 

Paralysis occurs in about one-half the cases in which the disease af- 
fects the lower cervical and upper dorsal vertebra?, but it is rare when 
the disease is below the middle dorsal region (see Compression Myelitis). 

Prognosis. — The actual mortality of Pott's disease is difficult to state, 
so many of the consequences of the disease being remote and not fully 
appreciated until adult life is reached. The general mortality from all 
causes is from ten to twenty per cent. The causes of death are exhaus- 
tion from prolonged suppuration, amyloid degeneration, myelitis, gen- 
eral tuberculosis, and tuberculous meningitis. Sudden death occasion- 
ally occurs from pressure upon the cord in the upper cervical region, 
or from the pressure effects of abscesses in the posterior pharynx or in 
the posterior mediastinum. 

The prognosis as to the amount of permanent deformity will depend 
upon the seat of the disease, the time at which treatment is begun, and 
upon the thoroughness with which it is carried out. The best results as 
to deformity are obtained when the disease is below the middle dorsal 
region. With improved methods of treatment begun early, a large 
number of these patients recover with an insignificant amount of de- 
formity, and some with none whatever. 

Diagnosis. — r J ne spinal deformity resulting from Pott's disease may 
be confounded with rachitic kyphosis or with rotary lateral curvature. 
Rachitic curvatures are usually seen in children under eighteen months 
of age, a time when Pott's disease is rare; there are other signs of rickets 
present, and instead of rigidity there is usually undue mobility of the 
spine. What is true of rickets may he said of all curvatures depending 
upon malnutrition. Rotary lateral curvature is seen about puberty. 
rarely in young children except in connection with pickets. A slight 
lateral deviation of the spine sometimes -ecu in the early stages of caries, 



Hll'-.JOINT DISEASE. 859 

may resemble a case of incipient rotary curvature. The latter is nol 
attended by pain or rigidity, and is most frequenl in young girls from 
eleven to fourteen years of age. 

Other abscesses may be mistaken for (hose dependent upon vertebral 
caries. This difficulty is likely to exist in the cases attended by very 
little spinal deformity. These abscesses are most frequently in the iliac 
fossa or in the lumbar region, and may be due to perinephritis or ap- 
pendicitis. The latter are more acute than those depending upon bone 
disease and usually accompanied by fever. Tumours of the vertebra? or 
of the spinal cord may give rise to symptoms almost identical with those 
resulting from compression myelitis due to Pott's disease, but both of 
these are extremely rare. 

Treatment. — The treatment of Pott's disease is both general and 
local, and neither should be neglected. The constitutional treatment 
should he similar to that employed in other forms of tuberculosis. 

The indications for local treatment are to put the diseased parts at 
rest, by immobilising the spine and removing the superincumbent weight 
of the body. With the great advances made in orthopaedic surgery it is 
no longer necessary to confine these patients in bed, as was formerly 
practised, to secure this result. It may be accomplished either by plaster- 
of-Paris, or some other form of jacket, or a properly fitting steel brace. 
A head-support should he attached to all forms of apparatus, if the 
disease is above the middle dorsal region. The closest attention to de- 
tails and much experience in the use of apparatus are required to secure 
the best results. In perhaps no class of cases have the beneficial results 
of modern scientific treatment been more apparent than in those of 
Pott's disease. For the details in regard to the mechanical treatment 
and the different forms of apparatus, the reader is referred to works on 
general or orthopaedic surgery. 

Articular Ostitis of the Hip — Hip-Joint Disease. 

In early childhood this generally begins as a chronic ostitis in the 
head of the femur, starting near the epiphyseal line. Exceptionally, 
and oftener in older children, it begins in the acetabulum. The path- 
ological process, as well as the clinical history, is generally described as 
consisting of three stages. In the first stage — that of ostitis — the lesions 
are limited to the bone; in the second stage — that of arthritis — all the 
joint structures are involved, and in this stage suppuration usually 
occurs; in the third stage there is breaking down and absorption of 
the head and sometimes of the neck of the femur, which, with destruc- 
tion of the ligaments, leads to marked displacement of the parts from 
muscular contraction. The disease may be arrested in the first or in 
the second stage, or it may continue through all three stages. 



860 DISEASES OF THE BONES VXD JOINTS. 

Symptoms. Clinically, the usual duration of the first stage is three 
or four months; it may last only for a few weeks, it may extend over two 
or three years, and the disease may be arrested in tins stage. The onset 
is usually very gradual, and the symptoms are often considered of trivial 
importance until they have continued for some weeks. Generally the 
first thing noticed is slight lameness, due to stiffness of the joint. In 
the beginning this may he Been only in the morning, wearing off during 
the day. It may he accompanied by some tenderness about the hip and 
a disinclination to walk. A little later the child complains of pain, 
which is most frequently referred to the front of the knee or the inner 
aspect o^i the thigh, hut only in rare cases to the hip itself. This is slight 
at first, but gradually increases in frequency and severity, and soon there 
are added the " starting pains " at night, which are one of the most 
characteristic features of early hip disease. These pains are produced by 
a sudden spasm of the muscles during sleep. The child often cries out 
sharply without waking, sometimes wakes with a cry; this is often re- 
peated several times during the night. Soon restlessness and fretfulness 
during the day are present. The lameness, which at first was slight and 
occasional, or noticed only in the morning, comes to be a constant symp- 
tom, and week by week increases in severity. The evolution of these 
symptoms may take only a few weeks, but sometimes they come and go 
in the most inexplicable manner during a period of several months, or 
even one to two years, before they are fully developed. 

Every child with a suspicious lameness, or with pains like those men- 
tioned, should be stripped and submitted to a thorough examination. 
The first points to be observed on inspection relate to the general con- 
tour of the hip; every prominence and depression should be carefully 
noted. Then the attitude and gait should be studied; and finally all 
the functions of the joint should be carefully tested, and the limbs 
measured, to determine the existence of shortening or atrophy. At every 
step a comparison should be made with the sound limb. The contour 
of the hip is changed quite uniformly; there is broadening and flatten- 
ing of the whole gluteal region; the trochanter is unnaturally promi- 
nent; the gluteal fold is shortened, and often single instead of double. 
There is no characteristic position of the limb in this stage. There is 
atrophy of the thigh and often of the calf. In Fig. 166 is shown the 
appearance of a typical ease in the full development of the first stage. 
In walking, the child favours the diseased side, throwing the weight as 
much as possible upon the sound limb; but all these symptoms are of 
much less importance for diagnosis than is an examination of the func- 
tions of the joint. 

For this purpose the child should be placed upon a table upon his 
back, and the various movements of the hip — abduction, adduction, 
flexion, extension, and rotation — should be executed, first with the 



1111' JOINT DISEASE 



861 



sound limb and then with the suspected one, the two being carefully 
compared at every point to determine the degree of motion allowed. It 
is not necessary that force should he employed or pain inflicted. If the 
symptoms have existed for some weeks, there 
is generally a limitation of motion at the hip 
in all directions, hut first usually in abduc- 
tion, rotation, or extension. In more advanced 
cases, no motion whatever may he permitted 
ai the joint, the pelvis tilting with the 1 slightest 
movement of the femur. This fixation of the 
hip is i\uc, to tonic muscular spasm. Crowd- 
ing the articular surfaces together, by pres- 
sure upon the heel or trochanter, produces pain, 
which is usually referred to the joint. This 
test should be carefully made, lest injury be 
inflicted. Gibney cautions against examina- 
tions under ether, since in this way serious 
injury may be done unconsciously. 

Second Stage. — This has been called the 
stage of arthritis. Its existence may be as- 
sumed when the limb takes the position of 
marked permanent deformity, which is due 
at this period to muscular action, not to de- 
structive bone changes. The transition from 
the first to the second stage is in most cases 
a gradual one, and the line between the two 
can not be sharply drawn; sometimes, how- 
ever, it is rapid, and marked by a sharp ex- 
acerbation of all the symptoms. This may 
indicate a sudden perforation of the joint and 
the rapid development of suppurative arthritis. 
Such is the usual result when an abscess which 
has been slowly forming in the bone opens into 
the joint; or acute joint inflammation may 

be lighted up without so evident a cause. Sometimes the pus reaches 
the surface below the capsular ligament, and the joint remains intact. 
An acute exacerbation is indicated by increased pain, excessive tender- 
ness about the hip, often by inability to walk, or even to bear any weight 
upon the limb, and frequently by fever. The position assumed by the 
limb is now fairly characteristic. The foot is generally everted, the 
thigh slightly flexed and rotated outward, and the limb apparently 
lengthened. There may be infiltration anywhere about the hip, due to 
the formation of an abscess. The muscular spasm is so great that the 
joint is locked — no motion whatever being allowed, Abscesses may form 




Fig. 166. — Hip- joint Dis- 
ease, AT THE End of the 
First Stage. Showing 
muscular atrophy, promi- 
nence of the trochanter, 
flattening of the gluteal 
region, and a single gluteal 
fold. 



862 DISEASES OF THE HONKS AND JOINTS. 

;it am point about the hip; they are especially frequent at the upper 
and outer aspect of the thigh, and may burrow Long distances before 
reaching the surface. The duration of the second stage also is indefinite, 
but it usually lasts from a few mouths to a year, or the disease may be 
arrested in this stage. 

Third Stage. — There is now marked deformity, which is the result of 
muscular contraction after absorption of the head and sometimes the 
neck o{ the femur, and destruction of the ligaments. The position of 
the limb is a very constant one, and resembles that present in dislocation 
upon the dorsum of the ilium. There is shortening of from one to four 
inches; the thigh is strongly flexed, adducted, and rotated inward, and 
the foot is inverted; the trochanter lies against the outer surface of the 
ilium, and is above Nelaton's line. In this position the joint may be- 
come ankylosed. The displacement usually conies on gradually, but it is 
sometimes so sudden as to be mistaken for a true dislocation, although 
the latter is exceedingly rare in the course of hip disease. 

There is now marked atrophy of all the muscles of the limh, and the 
thigh may be two or three inches smaller than its fellow. No motion at 
all is usually allowed at the hip, but this is compensated for to some 
degree by the exaggerated mobility of the lumbar spine. The spinal 
curvature — lordosis — is very marked both upon standing and walk- 
ing. The duration of this stage may be several years. From time to 
time exacerbations occur, often excited by falls, and accompanied by the 
formation of new abscesses. In protracted cases, all the soft parts about 
the hi]) may be seamed with cicatrices from old sinuses. After the dis- 
ease lias gone on to the third stage, cure can take place only by ankylosis. 

Diagnosis. — The important point in the early diagnosis of ostitis of 
the hip, is the gradual evolution of the symptoms, the most characteristic 
of which are lameness, " starting pains " at night, and impairment of 
all the functions of the joint. Mistakes in diagnosis most frequently 
arise from a failure to obtain a careful history, and from relying too 
much upon the s}nnptoms of lameness and deformity. The essentially 
chronic character of the disease should constantly be borne in mind. 
In the vast majority of cases, with a careful history and a thorough ex- 
amination, there can be but little doubt as to the diagnosis except at the 
very outset. The proportion of obscure and irregular cases to those 
following the regular course is small. 

'In the early stage, hip-joint disease may be confounded with a strain 
of the joint, with muscular rheumatism, poliomyelitis, periostitis of the 
shaft of the femur, phlegmonous inflammation in the neighbourhood of 
the joint, or with caries of the lumbar spine. In the second stage there 
is even less difficulty in diagnosis, although abscesses resulting from 
perinephritis or appendicitis have been mistaken for those arising from 
hip disease. In the third stage, a mistake is almost impossible. 



KNKK-JOIXT DISEAi 863 

Prognosis. — This is to be considered both with reference to life and 
limb. The records of the Hospital for Ruptured and Crippled show the 
mortality of hospital patients with hip disease to be nearly twenty-five 
per cent. This includes deaths directly or indirectly traceable to the 
disease. The causes are nearly the same as in caries of the spine — ex- 
haustion from prolonged suppuration, amyloid degeneration, and general 
tuberculosis or tuberculous meningitis. 

Under the most favourable conditions, the disease may be arrested in 
the first stage, and recovery occur without lameness or any noticeable 
impairment of the joint functions. This result, however, is not often 
obtained, because the disease is usually well advanced before it is recosr- 
nised, or because of the difficulty in the way of carrying out all the details 
of treatment in the best possible manner. If the disease has advanced 
to the second stage and suppuration has occurred, there always results 
some impairment of the joint functions ; usually there are decided lame- 
ness and marked muscular atrophy, but very little shortening or de- 
formity, provided the limb has been kept in the proper position. If the 
disease has advanced to the third stage, there are always marked short- 
ening, deformity, and lameness. 

Treatment. — The indications for constitutional treatment are the 
same as in caries of the spine. The purpose of local treatment is to 
secure constant and complete rest for the diseased parts, and to prevent 
deformity. Rest is secured by overcoming the muscular spasm by means 
of extension, by immobilising the joint, and by transferring the weight 
of the body, in walking, from the hip to the perinaeum. All these indi- 
cations are now met, while the patient is up and about, by the use of 
the most approved apparatus. The general opinion of orthopaedic sur- 
geons at the present day is against excision, except in cases where, in 
spite of treatment by apparatus, the disease has advanced to the third 
stage, and in cases where life is threatened from prolonged suppuration 
and exhaustion. 

Articular Ostitis of the Knee — Knee-Joint Disease — Wliite Swelling. 

Ostitis of the knee usually begins in one of the condyles of the femur, 
the inner much oftener than the outer one; less frequently it begins in 
the head of the tibia. The pathological process is very much like that 
at the hip. There is in the first stage a central ostitis accompanied by 
infiltration and expansion of the part of the bone affected. The disease 
may remain limited to the bone, the inflammatory products becoming 
encapsulated, or softening and breaking down may occur, with the for- 
mation of an abscess. Gradually the process extends outward, and the 
periosteum and the soft parts are involved. The disease may invade the 
joint itself in a destructive inflammation, or pus may escape externally 
without seriously involving the joint structures. The degree to which 



364 DISEASES "1 THE BONES AXD JOINTS. 

<mt is involved varies much in different cases: there may be only 
a simple synovitis, a suppurative arthritis, or a destruction of th< 
tilages and articular ends of the hones, synovial membrane, and liga- 
ments, so that in the advanced stage all traces of a joint structure 
are 1 

If the process remains limited to the hone, recovery may take place 
with very little impairment of the joint functions. If suppuration in 
the joint has taken place, there will he more or less stiffness and fibrous 
or bony ankylosis. When there is destruction of the ligaments and ar- 
ticular ends of the hones, the limb assumes a characteristic position — 
tlu' joint is flexed, the tibia is displaced backward and rotated outward, 
and there is marked over-riding of the femur. Bony ankylosis in this 
position is often seen. 

Symptoms. — The earliest symptoms of disease at the knee are usually 
a slight stiffness of the joint, with a disposition to flexion and slight 
lameness. At first these symptoms are noticed only occasionally; finally 
they become constant and there is pain, which is usually referred to the 
knee. In some cases there are " starting jDains " at night, although these 
are less constant and less severe than in hip disease. Swelling is noticed 
early, as the diseased parts are superficial. At first this is chiefly of the 
bone itself; the condyle, usually the inner one, is enlarged and elon- 
gated, often to a marked degree, before there is any infiltration of the 
soft parts. Later there is a general fusiform swelling, involving the 
entire joint and effacing all the normal outlines. Some tenderness upon 
pressure over the bone affected is present quite early, and there may be 
atrophy of the muscles of the thigh and calf. The knee is flexed and 
slightly rotated outward, the position which secures the most complete 
relaxation of the joint structures. In some cases there is seen the char- 
acteristic ^veiling due to distention of the synovial membrane. Abscesses 
may form anywhere about the joint; very frequently they burrow be- 
neath the tendon of the quadriceps extensor as far as the middle of the 
thigh. Gradually the deformity increases until the leg may be flexed at 
a right angle, and rotated outward over an arc of twenty or thirty 
degrees. 

The course of the disease resembles that of ostitis of the hip and the 
spine. During periods of remission pain and tenderness often subside 
eral months so completely as to lead to the supposition that the 
disease lias been arrested. An exacerbation is often excited by a fall or 
a strain of the joint, or it may follow an attack of acute illness. The 
disease may then progress rapidly and abscess after abscess form, with 
extensive destruction of all the joint structures and the production of 
permanent deformity. 

Prognosis. — The danger to life is considerably less than in disease of 
the hip or spine. Death, however, results from the same causes — exhaus- 



TUBERCUL01 S OSTEO-MYELITI& 865 

tion, amyloid degeneration, and general tuberculosis or tuberculous 
meningitis. 

With an early diagnosis and proper treatment the disease maj, in a 

considerable proportion of cases, remain Limited to the bone, and the 

resulting lameness and deformity be very slight; but otherwise a certain 
amount of lameness results from the stiffness of the joint. This mav be 
due either to fibrous thickening or to bony ankylosis. Nearly all pa- 
tients are able to walk without crutches, and if proper treatment has been 
carried out there is neither marked shortening nor deformity, although 
there is always great muscular atrophy. 

Diagnosis. — The important symptoms for diagnosis, are the gradual 
onset, the early swelling which is due to enlargement of the bone, and 
the constant lameness and deformity. The disease may be confounded 
with rheumatism, with synovitis, and even with scurvy. In all these 
cases the resemblance exists only during the period of exacerbation. A 
careful history, however, will usually clear up the diagnosis. 

Treatment. — The general treatment is the same as in other forms of 
joint disease. The indications for local treatment are the same as in 
hip disease — viz., to immobilise the affected limb and prevent deform- 
ity. This is accomplished by a form of apparatus which transfers 
the weight of the body from the joint to the perinaeum, and which over- 
comes the muscular spasm which produces flexion and inward rotation 
of the joint. As in hip disease, the results with mechanical and con- 
stitutional treatment are decidedly better than from early operative 
measures; but late operations are indicated under the same conditions. 

Tuberculous Osteo-Myelitis. 

This disease is rarely seen except in the short tubular bones, most 
frequently those of the hand and fingers. From this fact it is often 
called scrofulous or tuberculous dactylitis. It is described by many 
writers under the name of spina ventosa. TJnger gives the following 
figures showing the frequency with which the different bones were af- 
fected : Fingers in -13, toes in 3, metacarpus in 41, metatarsus in 1-i, 
radius in 2, ulna in 2, tibia in 3, jaw in 3. The first phalanx of the index 
finger is the bone which is most frequently the seat of disease. In the 
majority of cases the process is confined to a single bone, although it is 
not rare to see five or six affected. In such cases the disease is seldom 
symmetrical. The process is a chronic inflammation, beginning in the 
centre of the bone with the deposit of tuberculous material. The swell- 
ing which follows causes an expansion of the bone and thinning of the 
shaft, until a mere shell may remain. The later changes are inflamma- 
tion of the periosteum and the soft parts, the formation of abscesses and 
sinuses, necrosis, the exfoliation of sequestra, etc. The entire disease 
lasts from one to three years, and causes in most rases marked deformity. 
56 






DISEASES OF THE BONES AND JOINTS. 



Tuberculous dactylitis is essentially a disease of early childhood, be- 
ing seen most frequently during the second and third years. Jn a con- 
siderable proportion of the cases there is a family history of tuberculosis. 
The disease frequently appears to be the only tuberculous lesion in 
the body, hnt tuberculosis oi the hip, knee, ankle, or spine may be 
associated. 

Symptoms. — Tuberculous dactylitis usually begins as a painless en- 
largement of one of the phalanges, most frequently the first one of the 
index finger. It mav be two or three months before it is of sufficient 




Fig. 167. — Tuberculous Dactylitis of the First Phalanx of the Ixdex Fixger. 



size to attract much attention. Exceptionally the inflammation is a more 
active one, and is accompanied by both pain and tenderness. The swell- 
ing is quite characteristic : it is smooth, hard, uniform, and generally 
spindle-shaped, involving the entire phalanx of the affected finger. The 
appearance of a severe typical case is shown in Fig. 167. Later there is 
discolouration of the skin, and usually there is suppuration. The abscess 
generally opens at the side of the finger, and a curdy pus is evacuated. 
If the opening is enlarged by an incision there is found a cavity partly 
filled with caseous matter, and dead hone is felt, and perhaps a loose 
sequestrum. The cavity is surrounded by a thin shell of new bone, which 
is formed from the periosteum. If no operation is done the discharge 
continues for weeks or months, other abscesses often form, and finally 
1 small sequestra are exfoliated — sometimes a single large one, 
which is the shell of the diseased phalanx almost entire. 

Tn some cases the disease is arrested before necrosis occurs, but in the 
majority this is not bo. After the wounds have all healed the finger 



SYPHILITIC DISEASES OF THE BOxNES. 867 

remains shortened, deformed, and often useless. In some cases the dis- 
organisation is so extensive that amputation is necessary. 

Diagnosis. — The recognition of dactylitis is usually easy, but as symp- 
toms almost identical may be seen in a syphilitic Inflammation, it is 
often difficult to tell with which of the two forms one has to deal. The 
tuberculous form is very much more frequent; it may occur in a patient 
with tuberculous antecedents, or it may be associated with other tuber- 
culous lesions. Syphilitic cases are distinguished by the fact that the 
lesion is more frequently multiple, that it is often symmetrical, and that 
other manifestations of syphilis are generally present. The Wassermann 
and the tuberculin tests give definite information in nearly all cases. 

Treatment. — Painting with iodine and like measures are useless. 
The diseased part should be kept at rest — if a finger, by the application 
of a splint. Every means should be taken to build up the patient's gen- 
eral health, as this is the most effective way to influence the local process. 
The general verdict of surgeons is against early excision as a means of 
arresting the disease. Abscesses should be opened early and freely, all 
diseased bone removed, the finger kept in proper position, and the wound 
treated according to general surgical principles. Under almost any 
treatment the disease is a protracted one, and rarely lasts less than a year. 

SYPHILITIC DISEASES OF THE BONES. 

The bone lesions of hereditary syphilis are not infrequent, but were 
long unrecognised. They may be divided into two groups — those occur- 
ring with the early symptoms, and those which belong to the late mani- 
festations of the disease. 

Acute Epiphysitis. 

This is the most frequent variety of bone disease in early hereditary 
syphilis. It may begin even in intra-uterine life, and it forms one <>(' 
the most characteristic lesions of the disease. To some degree it is 
almost invariably present in syphilitic foetuses and in syphilitic infants 
who are still-born. 

In the early stage, there is an increase in the cartilage cells and often 
increased calcification. Later, a line of softening forms at the epiphyseal 
junction, which may cause loosening of the cartilages and ultimately 
complete separation of the epiphysis from the shaft, by the formation of 
granulation tissue between them. In cases receiving proper treatment, re- 
covery may take place with good union, perfect function, and without any 
deformity. In other cases degenerative changes continue, and infection 
with pyogenic germs may be added. The large joints are usually affected, 
and the lesions are frequently symmetrical. Acute suppurative arthritis 
may occur independently of changes at the epiphysis ; but even when these 



868 



DISEASES OF THE HONKS AM) JOINTS. 



n in syphilitic infants they are to be regarded as of pysemic rather 
than o\' syphilitic origin. Secondary to the changes at the epiphysis, 
there is periostitis. Periostitis of the shal'l is rare in early infancy. 

The bones most frequently the seat of acute epiphysitis are the hu- 
merus, radius, and ulna, although any of the long bones may be affected. 
Symptoms. — The early symptoms are usually quite acute, and appear 
during the first six weeks of life; they may precede any other mani- 
festations of syphilis. In some eases 
there is first noticed an inability on 
the part of the child to move the 
limb, which may easily be mistaken 
for paralysis. It is, in fact, often 
described as "syphilitic pseudo-paral- 
ysis." The limb lies perfectly mo- 
tionless, and any attempt at passive 
movement causes evident pain. There 
is tenderness on pressure, and soon 
swelling is seen, both being most 
marked at the epiphyseal line. If 
the bone affected is superficially sit- 
uated, as the lower epiphysis of the 
humerus, radius, or tibia, swelling is 
ver} r apparent, while it may be scarce- 
ly perceptible at the upper epiphysis 
of the humerus. The swelling is 
usuall}- cylindrical and moderate in 
degree, being limited to the extremity 
of the bone. Separation of the epi- 
physis may take place, so that crepi- 
tation is obtained by moving the limb. 
With this there is sometimes suppuration. The Kbntgen ray shows in 
many instances an increase in calcification at the epiphysis with an 
irregular serrated outline (Fig. 168) known as Gyons line. 

In the milder cases, or those which have been subjected to active 
treatment, both the swelling and the tenderness subside rapidly without 
suppuration; and even though the epiphysis has separated from the shaft, 
ii Bpeedily unites. When pseudo-paralysis has been the chief symptom, 
very rapid improvement occurs under treatment, and usually there is com- 
plete recovery of function in two or three weeks. If the disease extends to 
the joint, or if osteo-myelitis develops, the case is almost certainly fatal. 
Diagnosis. — This is usually easy, from the age of the patient — gener- 
ally under three months — the early prominence of pain and apparent 
Loss of power, with the later appearance of swelling and signs of inflam- 
mation at the epiphyseal junction. In all these respects the disease 




Fig. 1G8 —Hereditary Syphilis. 
Showing Gyon's line, A. Infant two 
months old. 



SYPHILITIC OSTEOPERIOSTITIS. 



869 



closely resembles scurvy ; but the latter is rare before the eighth or tenth 
month; there is usually a history of the long-continued use of some pro- 
prietary infant food, and it is cured by dietetic treatment alone. In 
ease of doubt the Wassermann test may be used. 

The apparent loss of power may lead to the diagnosis of birth palsy, 
especially of the upper-arm type. The presence of acute pain and ten- 
derness, the absence of the characteristic deformity, and the prompt 
recovery under constitutional treatment, usually make the distinction 
between the two conditions an easy one. 

Treatment. — This is the same as in all early syphilitic manifestations, 
for which see the article on Syphilis. Locally, the part requires in the 
early stage only protection and rest. Should suppuration occur in the 
neighbouring joint, or should osteo-myelitis develop, these conditions 
should be treated surgically, as they are when due to other causes. 

Oil ran ic Osteo-Periostitis. 

This is the usual form of bone disease which is seen in late hereditary 
syphilis, and it is one of the most frequent and most characteristic 




Fig. 169. — Syphilitic Periostitis of the Fibula. Infant throe months old. 
Same patient as Figs. 173-176. Right side affected; left side normal. 

lesions of that stage of the disease. It is occasionally seen in early in- 
fancy, and usually affects the long bones. The lesions are multiple, and 
at this age principally periosteal. The Rontgen ray picture shows a 
fusiform swelling chiefly due to periosteal thickening (Fig. 169). 



870 



DISEASES OF THE BONES AND JOINTS. 



Chronic osteo- periostitis is more frequent after the third year, and most 
of the cases occur between the fifth and fourteenth years. The most 
frequent seal o\' disease is the tibia, and oexi to this the hones of the 
forearm ami the cranium. The following is the frequency with which 
the different hones were affected in the series of cases reported by Pour- 
nier: tibia in !>1 cases, ulna in 22, radius in 15, cranium in 16, humerus 
in L2, all others in 37. The process may result either in a diffuse or a 
localised hyperplasia of hone or in necrosis. 

The typical changes are seen in the tibia. The shaft of the bone is 
principally or solely affected. There is often produced a very charac- 
teristic deformity, consisting of a forward curve of the anterior border 
o( the tibia, which has been compared to a sabre blade (Fig. 170, 171). 




Flo. 170. — Syphilitic 0steo-periO3TITI8 of the Tibia. Left tibia greatly enlarged; 
\ x / z inches longer than the right, and leg 2 inches larger in circumference; sabre-like 
anterior border. Right tibia normal; lesion of long standing. Patient 13 years old. 



In some cases the horn; is bent inward at its lower third, resembling 
somewhat a rachitic curvature. Sometimes the entire shaft of the 
hone is affected, and it may be greatly enlarged. A1 other times the 
swelling is chiefly near the epiphysis, where large bosses may form of 
sufficient size to interfere with the functions of the joint. Instead 
of affecting the bone uniformly, the disease; often affects only certain 



SYriHUTK 1 OSTEO-PERIOSTITIS. 



871 



parts, loading to the formation of large nodes which are more likely to 
be followed by necrosis than are the other lesions. In most of the cases 
the process is purely a hyperplastic one, leaving the bone permanently 
enlarged and the limb often lengthened. Less frequently, there occur 




Fig. 171. — Syphilitic Osteo-periostitis of the Left Tibia. 
Similar lesion to that shown in Fig. 170; patient 8 years old. The right tibia is normal. 



gummatous deposits in or beneath the periosteum, which may soften, 
suppurate, and lead to superficial necrosis, with the formation of sinuses 
that remain open until the sequestrum is exfoliated. Syphilitic deposits 
sometimes take place in the interior of the bones, generally near the 
articular ends (Fig. 171) ; these may soften and break down with ab- 
scesses, sinuses, etc.. very much after the manner of a tuberculous in- 
flammation (Fig. 172 ). 

The lesions of the other long hones are essentially the same as of 
the tibia. They are nearly always symmetrical and often multiple. In 






DISEASES OF THE BONES AND JOINTS. 



a case under mv observation in a boy of lour years, the disease in- 
volved both tibie, both radii, the righl ulna, the Lefl metatarsus, and the 
metacarpal bone of the left thumb. The course of syphilitic osteo-peri- 




Fig. 172. — Syphilitic Bone Lesions in a Boy Four Years Old. The lower end of the 
radius of both arms is enlarged as a result probably of former epiphysitis ; there are 
sinuses leading to dead bone over the metacarpal bone of the right thumb, and over 
the upper extremity of the left ulna. The last two are recent lesions. 



ostitis is very chronic, and some permanent deformity is the rule, unless 
cases come very early under treatment. 

When affecting the bones of the cranium the disease usually takes the 
form of a gummatous periostitis, which leads to the formation of large 
nodes. These may remain as permanent deformities, or they may break 
down and suppurate, with necrosis of one or both tables of the skull. 
This may be followed by inflammation of the dura, the pia, and even 
of the brain itself. 

Symptoms. — When the long bones are affected, the symptoms are 
pain, tenderness, and deformity. These come on very gradually, and 
often the deformity is noticed before either pain or tenderness is suffi- 
ciently marked to attract attention. The pain is regularly worse at 
night, and often felt only at that time; it may be mild and occasional, 
or so severe as virtually to prevent sleep. There is tenderness on pres- 
sure over the bones affected, the acuteness of which will depend upon 
the activity of the process. When suppuration occurs, it comes very 
slowly, and never with symptoms of acute inflammation. Sinuses usu- 
ally continue to discharge until a sequestrum is exfoliated. The course 



SYPHILITIC DACTYLITIS. 873 

of the disease is very tedious, and the whole duration is usually Beveraj 
years. 

When the cranium is affected, there are seen irregular nodes, espe- 
cially upon the frontal and parietal bones. They are from one to two 
inches in diameter, and project from one-eighth to one- fourth of an inch 
above the general outline of the skull. There may be pain, tenderness, 
softening, suppuration, and necrosis, as in the long bones. 

Diagnosis. — It is rare that disease of the bones of the cranium is due 
in childhood to any other cause than syphilis, and this disease may usu- 
ally be assumed to exist if traumatism can be excluded. The bosses 
upon the cranium in rickets are always large, smooth, and regular in 
position, and belong to infancy. 

Syphilitic disease of the long bones is recognised by the nocturnal 
pain, the tenderness and peculiar deformity, and by the association of 
other late manifestations of syphilis — i. e., the peculiar notched teeth, 
the interstitial keratitis, the enlarged epitrochlear glands, etc. Tuber- 
culous disease generally affects the articular ends of the bones; syphilis 
nearly always the shaft. The diffuse hyperplasia of the tibia and the 
sabre-like deformity of its anterior border are rarely, if ever, due to any 
other cause than syphilis. 

The deformities of the long bones have in some cases a certain resem- 
blance to those due to rickets, but the two conditions can hardly be con- 
fused if a careful examination is made. 

Treatment. — The constitutional treatment of these lesions is the same 
as that of the other late manifestations of syphilis; for details see the 
chapter on Syphilis. Surgical treatment is required in cases which ter- 
minate in necrosis, whether of the cranium or the extremities. They 
are to be managed like the same conditions in adults. 

Syp It Hit ic D a ctyl i t is . 

This belongs to a somewhat earlier period of syphilis than the dis- 
ease just described, and is usually seen in infants. It is not a frequent 
manifestation of syphilis, and as compared with tuberculous dactylitis it 
is much less common and occurs at an earlier age. It was first fully de- 
scribed by Taylor (New York). The symptoms closely resemble the tu- 
berculous form. It may begin as a periostitis, but more frequently as an 
osteo-myelitis. Like the tuberculous form, it may go on to suppuration 
and necrosis. According to Taylor, dactylitis is more often single than 
multiple, but in my own cases several phalanges have generally been in- 
volved, and the lesions have often been symmetrical. In one case, the 
first phalanx of every finger of both hands was affected. The Rontgen 
ray pictures show that the metacarpal bones are also involved in many 
cases (Figs. 175 and 17(5)- 

The symptoms and course of syphilitic dactylitis are essentially the 



S71 



DISEASES OF THE BONUS AND JOINTS. 



same as m the tuberculous form. The differentia] diagnosis is considered 
with the latter disease. The prognosis is much the same in the two vari- 
eties, with the exception thai in the early stage the syphilitic cases may 




Fig. 173. Fig. 174. 

Figs. 173, 174. — Syphilitic Dactylitis. On right hand first phalanges of forefinger and 
little finger affected; on left hand first phalanx of thumb and second phalanx of second 
finger. 

often be arrested by constitutional treatment. This is the same as in 
other late lesions of syphilis. The same local treatment should be em- 
ployed as in the tuberculous cases. 




175. Fig. 176. 

Figs. 175, 170. — Rontobn Ray of Same Hands. Note that besides the bones shown 
in the other pictures, two metacarpal bones (C, D) are affected in the left hand and 
the lower end of the radius (G) in the right hand. 



CONGENITAL [CHTHYOSIS. 875 

CHAPTER V. 

DISEASES OF THE SKIN. 

The skin at birth is covered with a whitish sebaceous secretion, the 
vernix caseosa. The skin itself is of a deep purplish colour, which 
changes to a bright red over the face and trunk in a few minutes, with 
the establishment of normal respiration, and in a few hours the whole 
body has the same tint. This excessive redness slowly fades during the 
first month, at the end of which time the skin has assumed the pale pink 
)f infancy. On the third or fourth day there may be seen the first signs 
of icterus ; this generally fades by the end of the second week. 

The epidermis which is present at birth soon loosens and is thrown 
off. This normal desquamation usually begins upon the fourth or fifth 
day, and is completed in ten days or two weeks. If the skin is fre- 
quently oiled and properly bathed, desquamation is scarcely noticeable 
unless a close examination is made. In some infants, especially those 
who are delicate and cachectic, it is very much more marked, and closely 
resembles that seen in scarlet fever. Eitter has described an exfoliative 
dermatitis of the newly born, appearing generally during the second 
and third weeks, a condition which is regarded by Kaposi as simply an 
exaggeration of the normal physiological desquamation. This process 
may be mistaken for that due to hereditary syphilis; the latter, however, 
is rarely general, appears later, and is much more prolonged. 

Perspiration is rarely present before the end of the fourth month, 
and is then seen only upon the forehead. In healthy infants it is 
scarcely noticeable during the first year. Copious perspiration is most 
frequently a symptom of rickets; less marked perspiration may occur 
with any general weakness or during acute illness. 

CONGENITAL ICHTHYOSIS. 

Congenital, or more properly fcetal, ichthyosis, sometimes known also 
as diffuse keratoma, is a rare disease, characterised by the formation, usu- 
ally all over the body, of a thick, horny epidermis resembling parchment. 
This is divided by fissures or shallow furrows into irregular patches; 
sometimes these are two or three inches wide, at others as small as a pin's 
head. The disease begins in the early months of fcetal life, and is an 
abnormality in the development of the skin, there being an excessive pro- 
liferation of the layers of the epidermis. 

Symptoms. — In the gravest form of the disease the child often lives 
but a few hours, and rarely more than a week. The openings of the 
nostrils and the ears may be occluded by the excessive production of 
epithelial cells. The eyes are in a condition of ectropion, and there are 






DISEASES OF TI1K SKIN. 



often deformities of the mouth and other orifices due to the contractions 
of the skin. The nails and hair are usually imperfectly developed. The 
hody seems incased in a hard, horny covering, and looks as if it had been 
varnished or covered with collodion. The skin cracks or splits and the 
edges curl up, an appearance which lias been aptly compared to the skin 
o( a boiled potato. 

In the milder form, the duration of life is indefinite, depending upon 
the degree of development of the disease; but even in such cases there 
arc frequently seen the deformities at the orifices of the body, and there 
may also be a continued exfoliation of the epidermis in large irregular 




Fig. 177. — Congenital Ichthyosis in a Child Ten Months Old. The large scaly- 
patches arc well shown on the lower part of the right chest and abdomen, and the 
constricting bands upon the legs. (From a photograph by Dr. Cabot.) 



patches. After this has separated, the skin beneath appears red and 
moist, hut gradually becomes dry. hard, and shining, slowly contracting 
until it splits in various directions. In a case recently under observation 
in the Babies 5 Hospital, a picture of which is shown in the accompanying 
illustration (Fig. 17 7 ), it was stated by the mother that during the first 
ten months of life complete exfoliation of the skin had occurred in the 
course of every two or three months. 

The outlook is bad in all cases; in most of the severe forms death 
occurs in infancy, but in some of the milder ones, life may be prolonged 
throughout childhood. The "alligator hoy" of the "Dime Museum" 
is an example of this class. 



MILIARIA. 877 

Treatment. — The indications are to keep the skin moisl and soft by 
the use of oils, continuous baths, etc., and to prevent infection by perfect 
cleanliness. Although a certain amount of improvement usually follows 
these measures, a cure is not to be expected. 



MILIARIA. 

The term miliaria is applied to an obstruction of the sweat glands, 
which may occur either with or without inflammation. The non-inflam- 
matory form is known as sudamina, the inflammatory forms as miliaria 
rubra, miliaria vesiculosa, and miliaria papulosa. 

Sudamina. — In this form there is no inflammation. The sweat ducts, 
according to Crocker, are blocked by an accumulation of epithelial cells 
while no perspiration is going on; and when the process is restored the 
fluid, being unable to escape, accumulates in the form of tiny vesicles. 
These appear like small pearly bodies very closely set, and disappear in 
the course of a few days by absorption. Fresh crops may appear from 
time to time. Sudamina may be seen in any of the continued fevers or 
exhausting diseases. It requires no treatment. 

Miliaria Rubra. — This condition, also known as red gum, strophulus, 
etc.. is a sweat rash, usually seen in young infants as the result of ex- 
cessive clothing. It is most frequently observed upon the cheeks and 
neck, often upon the side of the face upon which the infant sleeps, or the 
side held against the mother's body wdiile nursing, if this is done upon 
only one breast. The eruption consists of scattered red papules, some- 
times with tiny vesicles. Miliaria rubra is an inflammation about the 
sweat glands, the result of which is a retention of their secretion. There 
is generally little or no itching. The treatment consists in the removal 
of the cause, and the application of some absorbent powder, such as 
boric acid and starch. 

Miliaria Papulosa (Lichen Tropicus, Prickly Heat, etc.). — This is the 
most common and most important variety of miliaria. There is in this 
disease an obstruction of the sweat glands by inflammatory products. 
The lesion consists in the formation of bright-red papules, which are 
very closely set, the summits of some of them being surmounted by tiny 
vesicles, and here and there in severe cases even small pustules may he 
seen. If not interfered with by scratching, the vesicles dry up without 
rupture, and are followed by a slight desquamation. Where there is much 
scratching, an eczematous condition may result. Miliaria papulosa comes 
out with great rapidity, especially upon the neck, forehead, hack, and 
chest. It is accompanied by an almost intolerable itching and stinging 
sensation. Over other parts of the body profuse perspiration occurs. 
The disease is produced by very hot weather and excessive clothing. 
Although the duration of a single attack is but two or three days, in 



S7S DISEASES OF THE SKIN. 

susceptible patients it mnv keep recurring for weeks, being exceedingly 
intractable. Wnere there is much scratching the resulting eczema is 
very troublesome. It is not infrequently followed by furunculpsis. 

The diagnosis of miliaria rubra and miliaria papulosa is usually easy. 
They are distinguished from eczema by the suddenness with which they 
appear, by the associated sweating of other parts of the body, by the 
transitory character o\' the eruption, and by the fact that the rash never 
occurs in circumscribed patches. Prickly heat sometimes resemhles the 
rash of scarlet fever, but the fact that the tiny papules arc in some places 
crowned by vesicles and that constitutional symptoms are absent, usually 
make the distinction an easy one. 

Treatment. — Prickly heat is to be prevented by light clothing, fre- 
quent bathing, and the plentiful use of a good toilet powder, such as 
boric acid and starch. The skin should be protected against the irrita- 
tion of flannel undergarments by the interposition of silk or linen. When 
the inflammation is at its height, relief is obtained by the application of 
a calamine and zinc lotion, or by a dilute solution of the acetate of lead; 
carbolic acid may be added to either, where the itching is intense. In 
some cases powders are preferable to lotions. One of the best is the 
stearate or the oxide of zinc, twelve parts; bismuth, three parts; pow- 
dered camphor, one part ; or equal parts of starch and boric acid may be 
used, or simply rice flour. All of these must be very freely applied. 
The diet should be light and fluid, and if milk is the food it should be 
considerably diluted. 

SEBORRHEA. 

Scborrhcea is considered by dermatologists generally, as a functional 
disease of the sebaceous glands; although Unna regards all such cases 
as inflammatory, and classes them as seborrhceic eczema, which is of para- 
sit ic origin. The disease may affect almost any part of the body, and 
children of any age, but the most frequent form is that which is seen 
upon the scalp in young infants. This is the most important variety, 
and the only one which will be here considered. 

Seborrhcea of the scalp is characterised by the formation upon the 
vertex, of dirty -yellow crusts, which are soft, greasy, and friable. They 
are composed of epithelial cells, fat-globules, and granular masses, to 
which is always added dirt. In neglected cases the hairy scalp is nearly 
covered by a dense crust, which may be as thick as heavy pasteboard. 
If the crusts arc.' removed the underlying scalp may be found perfectly 
healthy, hut more frequently, in cases of long standing, it is eczematous. 
The eczema is set up by the decomposition of the exudation, or by the 
efforts to remove the crusts by such means as the fine-toothed comb, 
commonly employed in domestic practice. r l Tiere is little tendency to 
spontaneous improvement or recovery, and the condition often lasts for 



ECZEMA. S7 ( .) 

months. Every seborrhoea should be treated, for when neglected it 
furnishes a favourable soil for the developmenl of eczema. 

Treatment. — Only local measures arc required. The crusts are first 
to be softened with oil, and then removed by washing thoroughly with 
warm water and soap, after which an ointment of resorcin ( resorcin, gr. 
x; ungt. aquae rosae, 5J) or sulphur (precipitated sulphur, 3j; lanoline, 
gj) should be applied. The oil and soap and water are repeated every 
few days, or as often as the crusts form. In the meantime the scalp is 
kept covered with the ointment. 

ECZEMA. 

Eczema may be denned as a catarrhal inflammation of the skin. It 
is the'most frequent and altogether the most important disease of the 
skin in early life. The scope of the present work permits only a dis- 
cussion of such features and varieties as are peculiar to infants and 
young children. The eczema of older children does not differ in any 
essential points from that of adults. 

Etiology. — The conditions in infancy which predispose to eczema are, 
first, that the skin is extremely delicate, and hence more easily affected 
by external irritants and micro-organisms; secondly, its more intense 
glandular activity. While all children are susceptible, there are certain 
ones in whom the susceptibility is very marked, and in them the slightest 
amount of external irritation, or the most trivial disturbance of diges- 
tion may produce a severe eruption. We can not connect eczema with 
any single diathetic condition; but it is much more often seen in chil- 
dren with so-called gouty antecedents than in others. Such children 
are often in later life the subjects of asthma. Eczema of the face is 
common in fat, healthy-looking infants, both in those who are nursing 
and in those who are artificially fed. It rarely occurs in poorly nour- 
ished children. 

The exciting causes of eczema may be external or internal. Of the 
former the most important are heat, cold dry air, and winds — as in the 
familiar chapping of the face — the use of hard water or of strong soaps 
in bathing. The disease may be due to the irritation of clothing, to 
want of cleanliness, or to irritating discharges from mucous surfaces, as 
in the eczema of the upper lip, thighs, or buttocks. It accompanies most 
of the parasitic skin diseases, particularly pediculosis, scabies, and ring- 
worm. 

What part is played by micro-organisms in the etiology of eczema has 
not yet been fully determined. As a primary factor they do not seem 
to be of the first importance. Secondary infection, however, occurs in 
most cases, and this is important in keeping up the disease. 

The internal causes of eczema are chiefly associated with deficient 
elimination from the kidneys and bowels, and digestive disturbances. It 



880 DISEASES OF THE SKIN. 

often accompanies chronic constipation, especially when this is due to 
an excess of fat in the food. Eczema is also seen where the urine is 
scantv and concentrated because children partake too largely of solid 
i'oo(\. The latter is true both in the first and second years. 

Eczema may be produced by any form of digestive disturbance, but 
it is especially frequent in the intestinal indigestion which results from 
overfeeding, or the too early or excessive use of farinaceous food, or from 
breast-milk in which the percentage of fat is very high. Of farinaceous 
articles, the two which are most often to be blamed are potato and oat- 
meal. Although eczematous patients usually appear to be well nour- 
ished, it is rare that some symptoms of indigestion are not present. 

Eczema is often due to some form of reflex irritation. Such are the 
cases which accompany dentition, and the rare ones due to genital irrita- 
tion. By many writers the eczema caused by disorders of the stomach 
or intestines is regarded as reflex. The stronger the predisposition, the 
more trivial is the reflex irritation required to induce an eruption. 

Simple Chronic Eczema — Eczema Rubrum. — This is the most frequent 
form of eczema occurring in infants and young children, and is usually 
seen upon the face. It affects by preference the cheeks, forehead, and 
scalp, not infrequently the ears and neck, and may occur upon any part 
of the body. Upon the trunk and extremities the eruption is usually in 
patches, but in rare cases may cover nearly the entire body. The disease 
generally begins upon the cheeks with the formation of small red papules; 
later these coalesce, and there is a moist, red surface exuding serum or 
sero-pus. The secretion dries and forms thick, gummy crusts, which 
may be so hard as to form a mask for the face. From the scratching 
caused by the almost intolerable itching, the surface bleeds freely, and 
the dried blood gives to the crusts a dirty-brown colour and adds to the 
distressing appearance. The skin is often much swollen. After the 
removal of the crusts there is seen, in acute cases, a red, inflamed, gran- 
ular surface, discharging pus or serum and bleeding readily. When the 
process is less active, there is redness, thickening, induration, and scali- 
ness of the skin, and marked itching. In the same case these stages 
may alternate, exacerbations occurring whenever the exciting cause is 
particularly active. From the cheeks the disease spreads to the forehead, 
ears, and scalp, and here similar lesions are seen. Upon the trunk and 
extremities thick crusts rarely form, but the skin is red, thick, and scaly. 
The parts most often affected are the forearms, chest, elbows, knees, 
abdomen, and back ; occasionally the eruption is general. Eczema of the 
occipital region of the scalp is usually due to pediculosis. 

Swelling of the lymph nodes in the neighbourhood of the eruption 
is a constant feature of eczema of the face and scalp; these may reach 
the size of a chestnut or walnut, and occasionally they may suppurate. 
[ntense itching is a characteristic feature of all cases of eczema of the face 



ECZEMA. 881 

or scalp. While most children with eczema are well nourished in the 
beginning, and some remain so during a prolonged attack, the general 
health of many is undermined. The itching and discomfort cause con- 
stant irritability, loss of sleep and other nervous symptoms which some- 
times seriously impair the child's nutrition. 

The effects of very extensive eczema resemble in some particulars 
those of burns of the second degree. There may be fever, delirium, other 
nervous symptoms and even a fatal termination. Four cases have been 
seen recently in the Babies' Hospital with a generalised eczema in which 
there developed, without evident cause, exceedingly high temperature, 
in two cases reaching 109° F., accompanied by symptoms of a most 
profound intoxication. Two of the four cases ended fatally; one child 
in whom the temperature reached 109° F. recovered. In two of the 
patients a marked degree of acetonuria was present. No satisfactory 
explanation of these severe intoxications has yet been offered. 

There are some patients in whom an alternation of eczema and attacks 
of bronchitis with asthma may occur. During the eczema, the pulmonary 
symptoms are entirely wanting; but when the eczema is relieved the pul- 
monary symptoms rapidly develop. This is often seen in patients of the 
so-called gouty diathesis. In a few patients an alternation of eczema 
and diarrhoea is observed. 

Eczema of the face is very chronic, easily improved, but cured only 
with great difficulty. There is a strong tendency to relapse, brought on 
by neglect of local treatment or by any digestive disturbance. 

The predisposition to eczema often ceases with the second year; those 
who have suffered from it almost constantly during infancy may be free 
from it during the remainder of childhood. This is in part to be ex- 
plained by the loss of fat in consequence of more active exercise and a 
diet which is more largely nitrogenous. "Where the disease continues 
through the third and fourth years, the associated infantile condition — 
obesity — is not infrequently present. 

Pustular Eczema of the Scalp. — This condition, often called " simple 
impetigo," is less frequently seen in infants than in children from two 
to five years old. There are usually present from half a dozen to fifty 
greenish-yellow crusts, matting the hair, usually discrete, but sometimes 
coalescing to form a mask over half the scalp. There is very little itch- 
ing, in some cases none at all. The lymph glands are invariably en- 
larged. There is frequently continued auto-infection, and in this way 
the disease may be prolonged indefinitely. It is possible, too, that infec- 
tion may spread to other children. 

Intertrigo. — This term is rather indiscriminately applied to any erup- 
tion which develops upon two moist surfaces, which are in contact. It 
is often regarded as a form of eczema. There may be a simple erythema 
or an eczema resulting from traumatism or the decomposition of secre- 
57 



882 DISEASES OF THE SKIN. 

lions. Intertrigo is soon in the folds of the groin, between the scrotum 
and the thighs, between the buttocks, aboul the anus, in the axilla?, in 
the nook, or behind the ears. Its essential causes are moisture, friction, 
want o( cleanliness, ami sometimes infection. The disease is generally 
seen in its worst form about the thighs, genitals, and buttocks; it some- 
times covers the sacrum and extends down to the middle of the thighs. 
There is an intense uniform redness, and in some cases the epidermis is 
denuded over large areas, and the surface is moist. There is no thick 
crusting and little or no itching. Intertrigo is usually easy to control 
except in very poorly nourished or marantic children, among whom it is 
especially frequent. 

Diagnosis of Eczema. — This is usually quite an easy matter. In the 
majority of cases, the disease affects the face or the scalp, and its appear- 
ances are typical. Eczema of the body or extremities may be confounded 
with scabies or syphilis, and occasionally with other forms of skin dis- 
ease. Scabies resembles eczema in its intense itching and multiform 
lesions; but in the former, one may often find evidences of its presence 
in other members of the family; the parts most frequently affected are 
the flexures of the wrists, the elbows, the skin between the fingers, the 
margins of the axillae, the lower part of the abdomen and back, and, in 
boys, the penis; and by careful examination with a lens some of the 
characteristic burrows are certain to be discovered. 

Syphilis is likely to be confounded with papular eczema of the but- 
tocks. The latter affects the parts near the anus, and the irritation may 
lead to the development of spots closely resembling mucous patches. The 
local appearances may at times be indistinguishable from syphilis, and 
the diagnosis is to be made only by the other symptoms present. In 
syphilis the characteristic eruption is seen usually upon the face, hands, 
legs, and sometimes the palms and soles; there is no itching and very 
little evidence of inflammation; the eruption is copper-coloured, and 
occurs as small circumscribed spots ; there are usually present other symp- 
toms, such as the coryza, the syphilitic cachexia, and enlargement of the 
spleen. 

The diagnosis from pediculosis and ring-worm of the scalp, rarely 
presents any difficulties. 

Prognosis. — All cases of chronic eczema are tedious. There is only a 
slight tendency to spontaneous improvement, and very little to spontane- 
ous recovery during early infancy. About the end of the first year the 
disease disappears in many children; some relapse after this time, but 
others are never again troubled with eczema. In a severe case of gen- 
eral eczema the possibility of the development of severe toxic symptoms 
should not be forgotten. In a given case, the prognosis depends upon 
the duration of the disease, its severity, and very much upon the co- 
operation of the mother or nurse. The results obtained depend not 



ECZEMA. 883 

only upon the particular line of treatment adopted, but upon how well 
it is carried out. Usually it must be continued for several months. 
Eczema of the face is especially intractable when occurring in children 
suffering from chronic indigestion and constipation. Intertrigo is in 
most cases easily cured, unless the patient is suffering from marasmus. 

Treatment. — A judicious combination of general and local measures 
is necessary for the best results. One should first seek to discover and 
correct what is wrong with the child's digestion, assimilation, and elimi- 
nation ; unless nutritive disturbances can be removed, local treatment will 
give only temporary relief. External causes also must be investigated. 
The local measures employed must be chosen with reference to the con- 
dition present; stimulating applications should not be ordered for an 
acutely inflamed skin, nor sedative applications in very chronic con- 
ditions. 

Diet. — A thorough investigation into the food is necessary, not only 
as to its character, but as to quantity and preparation, the manner and 
frequency of feeding, etc. If the patient is a nursing infant, an exami- 
nation of the nurse's milk is indispensable to intelligent treatment. If 
the child is very fat and well nourished, it is generally the case that the 
fat of the milk is too high and must be reduced according to the rules 
given elsewhere, the most important thing being to exclude from the 
nurse's diet malt liquors and alcohol in all forms, and reduce the amount 
of meat. The amount of food should be reduced by lengthening the 
period between the nursings, and shortening the time which the child is 
allowed to remain at the breast at one nursing. Plain water, or better, 
some alkaline water, should be given freely between the nursings. In 
children fed upon cow's milk, the trouble may be with the sugar, or 
more frequently with the fat. This should first be reduced and if no 
improvement occurs the sugar should also be diminished. In all dietetic 
changes the general nutrition of the child should be regarded as more 
important than the relief of the eczema. 

During the latter part of the first and the entire second year, the 
usual error is that of overfeeding with in most cases an excessive use 
of solid food, especially farinaceous articles. The diet should then be 
much reduced, and the amount of farinaceous food restricted, potatoes 
and oatmeal being absolutely prohibited. The diet which suits most 
children best is one composed of milk, beef juice, broth, fruit, eggs, and 
a little red meat, with the addition in some cases of rice, wheat, or barley. 
In severe and obstinate cases, however, as complete a change in diet as 
possible is sometimes the best prescription. Any form of indigestion 
which exists is to be managed according to the special indications in 
each case. 

The diet of older children needs to be watched no less closely than 
that of infants. The general rules laid down elsewhere for feeding after 



ggj DISEASES OF THE SKIN. 

the second year should be observed. The great majority of eases do best 
upon a diet whieh is largely fluid, and composed of milk, buttermilk, 
kumyse or matzoon. 

Elimination by the kidneys should be stimulated by the very free use 
o( water, to which may be added the citrate, or acetate of potassium, 
from ten to twenty grains daily. 

Attention to the condition of the bowels is of the greatest importance. 
To overcome the tendency to constipation is in many cases to cure the 
eczema. Suggestions under this head will be found in the chapter on 
Chronic Constipation. The occasional use of catharsis by calomel every 
week or ten days is often beneficial. The best effects from this are seen 
in overfed children. It has a favourable effect upon the kidneys as well 
as upon the bowels. The bowels must not only be opened, they must 
be kept open by the daily use, if necessary, of some of the milder 
laxatives, such as magnesia, phosphate of sodium, rhubarb, or eas- 
eara. Castor oil, given in from half a teaspoonful to teaspoonful doses 
every night for two or three weeks at a time, is at times a useful 
measure. 

When the disease occurs in flabby, anaemic, or poorly nourished chil- 
dren, iron and bitter tonics are required, but rarely cod-liver oil. In 
other words, the child's general condition should be treated just as if 
no eczema existed. Arsenic is indicated in a chronic or recurring form 
of eczema with dry, scaly eruption. It is in no sense a specific remedy, 
but is sometimes of value. 

The general management of cases is important. The skin must be 
carefully protected by an ointment whenever the child is in the open 
air; if the weather is very cold, or there are high winds, children with 
active eczema should not go out, but be aired indoors. Never should 
an eczematous surface be washed with plain water, and much less with 
castile soap and water, so frequently employed by the ignorant. Where 
washing is necessary, it may be done with bran water, milk and water, 
or starch and water, to which borax (a teaspoonful to the quart) may be 
added. The clothing should not be so excessive as to keep the child- 
constantly in a perspiration. Napkins should not be washed in strong 
soda solutions, nor, in case of eczema of the buttocks, should they ever 
be used a second time after being simply dried. 

In eczema of the face it is absolutely necessary to prevent the child 
from scratching the parts. The use of a mask is not always sufficient, 
nor the wearing of mittens; nor is the local application of anti-pruritic 
lotions or ointments invariably successful. In severe cases mechanical 
restraint is absolutely indispensable. The most satisfactory method is to 
surround the arms at the elbows by pasteboard splints, and hold them in 
place by bandages. This allows free use of the hands, but makes it 
absolutely impossible for the child to reach the face. 



ECZEMA. 885 

Local Treatment. — Local treatment is always necessary, for not only 
are the causes sometimes entirely external, but the condition may per 
after the original internal cause has been removed. There arc Beveral 
indications to be met by local treatment at different stages in the disea 
(1) To remove crusts and other inflammatory products; (2) to allay 
congestion and acute inflammation; (3) to relieve itching; (4) to pro- 
tect the delicate new skin which is forming; (5) to prevent infection; 
(6) to stimulate the skin in the chronic stages of the disease. 

Preparatory to the use of any application, the scales, crusts, and other 
products of inflammation must be softened and removed in order that 
the diseased surface may be reached. In mosi cases it is sufficient to 
soften the crusts by the use of olive oil for twelve or twenty-four hours, 
and then remove them by soap and warm water. If the crusts are very 
hard and thick, they can be softened by a poultice. During the stage of 
acute inflammation only sedative applications should be used. One of 
the best of these is a lotion of zinc and calamine : 

^ Pulv. calaminae preparatae 3 ij 

Zinci oxidi I ss. 

Glycerinae § j 

Liquor calcis 5 ij 

Aquae rosae § viij . 

A piece of muslin should be dipped in this solution, and applied to 
the affected part, being kept in place by a bandage. If there is much 
itching, one per cent of carbolic acid may be added. 

Another plan of treatment, where there is much secretion, is to keep 
the surface covered with equal parts of boric acid and starch or talcum 
powder. An application which is often successful in allaying the in- 
tense burning and itching is black wash. This is applied several times 
a day in full strength or diluted and allowed to dry on, after which a 
protective ointment is used. 

A soothing application in general eczema is one composed of equal 
parts of lime-water and sweet-almond oil ; sometimes this may be advan- 
tageously followed by smearing the body with a thick starch paste and 
allowing it to dry on. 

As a simple protective ointment, one containing starch, zinc oxide, 

or bismuth, either alone or in combination, may be used. An excellent 

formula is Lassar's paste: 

5 Acidi salicylici gr. x 

Zinci oxidi 3 ij 

Amyli 3 ij 

Vaseline I J- 

Later, when the inflammation is less acute and the itching severe, 
nothing is so generally useful as a combination of tar and zinc, as in 
the following: 



886 DISEASES OF THE SKIN. 

B Ungt . pit-is liquids 3 iij 

Ziiu'i oxidi 3 iss. 

Tngt . aquae rose . 3 vi. 

For more chronic cases, the amount of tar may be increased. All 
ointments used should be spread upon muslin, and kept in close contact 
with the inflamed part by means of a bandage or mask. Little or noth- 
ing is accomplished by simply rubbing the ointment upon the affected 
part. Where it is difficult to keep a mask applied, or in situations where 
it is impossible to use the ointment, Pick's paste may be tried: 

3 Pulv. tragacanthae 3 j 

Glycerins? 3 iss. 

Aquae rosae § iv. 

To this may be added zinc oxide, gr. xl, and carbolic acid, gr. v, or tar, TTL 
x. A similar basis for ointments, made from gum tragacanth has been 
suggested by Elliot and is known as bassorin paste. It may be combined 
with tar, zinc, salicylic acid, or resorcin. An ointment containing five or 
ten per cent of calomel is often the best application for an eczema which 
is not too extensive. 

The methods of treatment above mentioned are especially applicable 
to eczema of the face and scalp. For pustular eczema of the scalp the 
best application is the white precipitate ointment, which should be com- 
bined with three or four parts of vaseline. This is excellent also for 
small eczematous patches upon the body, but it is not to be used over a 
large surface. 

In intertrigo, the treatment should have reference to the patholog- 
ical condition which is present. Cases of simple erythema usually yield 
promptly to cleanliness and the free use of absorbent antiseptic powders, 
such as boric acid and starch in equal parts, or calomel two per cent may 
be used with talcum. If there is an acute dermatitis, the calamine and 
zinc lotion may be used, and later some protecting ointment. When in- 
fection has been added, lotions of resorcin or ichthyol, one-half or one 
per cent strength, should first be applied, and the skin then covered 
with one of the powders mentioned; both are to be repeated as often 
as the parts are wet by urine or soiled by faeces. It is important in all 
cases that the diseased surfaces should be kept separated, which is best 
done by boric acid and starch. All napkins should be immediately re- 
moved when soiled. 

In cases of chronic eczema, where the skin remains thickened, red, 
scaly, and itching, stimulating applications are to be used, such as the 
tincture of green soap or stronger preparations of tar than those men- 
tioned. They should be applied every three or four days. 



FURUNCULOSIS. 887 



FURUNCULOSIS. 



A furuncle, or boil, is a circumscribed inflammation of the subcuta- 
neous cellular tissue, usually beginning in a hair follicle, and usually 
ending in suppuration. When severe, it may result in necrosis of the 
follicle, which forms the " core," or the necrotic process may extend to 
the surrounding tissues for a variable distance. The ordinary boil need 
not be described, as it presents nothing peculiar in early life. The con- 
dition, however, which is characteristic of young children is the forma- 
tion of small ones in great numbers. It is to this more especially that 
the term furunculosis is applied. The principal location of these small 
abscesses is, in nearly all cases, the scalp, face, and shoulders, although 
they may be found upon any part of the body. They are sometimes 
numbered by hundreds, and appear in crops for a period of several 
months. In size, they usually vary from a pea to an almond, and they 
rarely contain a core. Infants are much more often the subjects of this 
disease than are those who have passed the second year. In the great 
majority of cases the condition is not serious, yet, occurring, as it often 
does, in infants who are already suffering from extreme malnutrition 
or marasmus, whose tissues possess but little resistance, the process may 
develop into a gangrenous dermatitis, which may prove fatal. 

Furunculosis is seen in children who are in other respects apparently 
healthy, even robust; but the majority are in a more or less debilitated 
condition, and often are the subjects of digestive disturbances. The dis- 
ease is quite frequent in syphilitic infants ; but these simple abscesses are 
to be sharply distinguished from those which result from the breaking 
down of gummata of the skin. Want of cleanliness of the skin is a 
factor of some importance in producing the disease. Furunculosis may 
be associated with eczema. The exciting cause in all cases, as shown by 
recent investigations, is the entrance of the staphylococcus pyogenes 
aureus, sometimes with other organisms, into the follicles of the skin. 

Treatment. — The internal treatment is to be directed toward any dis- 
turbance of digestion or general nutrition which is present. General 
tonics are indicated in most cases, particularly iron, arsenic, and the com- 
pound syrup of the hypophosphites. But little reliance can be placed 
upon drugs such as sulphide of calcium, for the purpose of arresting 
this disease. Striking benefit, however, often follows the internal use 
of yeast; either brewer's yeast or the ordinary commercial yeast cake, 
freshly made, may be given. The latter is usually easier to obtain. To 
a child of two or three years one-fourth to one-half a yeast cake or about 
half a teaspoonful may be administered daily. Local treatment should 
have for its first object thorough cleanliness of the skin. This is best 
secured by frequently bathing the parts affected with a 1 to 5,000 solution 
of bichloride. Single furuncles may often be aborted by touching them 



SSS DISEASES OF THE SKIN. 

with pure carbolic acid or the application ot Bier's cups. In my ex- 
perience the besl plan of treating the multiple small furuncles, is to 
delay incision until they have pointed, then to incise and empty the 
follicle completely by compression. After this the part should he cov- 
ered with simple collodion. Where the abscesses are of large size and 
upon the scalp, it is wise to make compression by applying a snug band- 
age for a day. When the suppuration is more diffuse and there is 
necrosis of the cellular tissue, ichthyol, either in the form of an ointment 
or lotion (one to five per cent strength) is one of the best applications. 
For general furunculosis or the continual recurrence of larger abscesses 
the use of vaccines is altogether the most effective treatment. While 
autogenous vaccines are perhaps preferable, the use of stock vaccines is 
in most cases equally effective. Injections should be repeated every 
three or four days; beginning with fifty millions, the dose may be 
increased to one hundred millions. The results in most cases are very 
striking. 

GANGRENOUS DERMATITIS. 

This is not a frequent disease, and is seen almost exclusively in in- 
fancy. It may be primary or it may follow other diseases, and hence has 
been described under many different names, viz., varicella gangrenosa, 
ecthyma gangrenosa, pemphigus gangrenosa, etc. 

The lesion consists in small, discrete areas of inflammation of the 
skin, ending in necrosis. In the primary cases there is usually first seen 
a vesicle, about as large as a pea, with a dusky areola; it increases in 
size and becomes a pustule. Crusts form which are quite adherent, and 
on removing them a loss of tissue is seen. The ulcers usually have 
sharp but not undermined edges, often presenting a " punched-out " ap- 
pearance. By the coalescence of several small ones, ulcers an inch or 
more in diameter are sometimes formed. 

The primary form of gangrenous dermatitis occurs in wretched, 
poorly-nourished infants, and is most often seen upon the buttocks. In 
this location it may be mistaken for syphilis. The secondary form is 
more common, and usually follows varicella, less frequently vaccinia, or 
impetigo. In such cases the lesion is usually seen upon the upper half 
of the body, especially upon the neck and chest. It follows the ordinary 
lesions of varicella and continues usually, in spite of treatment, from 
one to four weeks, in many cases ending fatally. The disease always 
occurs in infants of poor vitality, often in those suffering from maras- 
mus, and is seldom seen outside of institutions. It may be accompanied 
by fever, and other severe constitutional symptoms. 

For the production of the disease, two factors are necessary : First, 
'institutional condition referred to; and, secondly, the entrance of 
pyogenic germs, usually the streptococcus pyogenes. 



IMPETIGO CONTAGIOSA. 889 

Treatment. — Every means possible should be employed to build up 
the general health of the infant by tonics, fresh air, careful feeding, etc. 
Locally, strict cleanliness and antiseptic applications are necessary. The 
best application is a solution of bichloride (1 to 5,000), or an ointment 
of ichthyol or white precipitate. 

IMPETIGO CONTAGIOSA. 

Impetigo contagiosa is a disease characterised by the formation of 
discrete vesiculo-pustules, occurring most frequently upon the hands 
and face. Cases are usually seen in groups affecting several children in 
one family or institution. It may be communicated from one person 
to another, and spread by auto-inoculation from one part of the body 
to another. 

One rarely has an opportunity to see the disease until vesicles have 
formed. These are usually from one-fourth to one-half inch in diam- 
eter, and are flaccid, never distended. Later, their contents become 
slightly yellowish; then they rupture and dry, forming thick yellow 
crusts, which have the appearance of being " stuck on," the surrounding 
skin being quite healthy. After the crusts fall off, a small red patch 
remains, which slowly fades. The true skin is not involved, except in 
poorly nourished, cachectic subjects, as a result of continued local irrita- 
tion, like scratching. Under such conditions ulceration may occur. 
Instead of the small vesiculo-pustules described, bullae from one to two 
inches in diameter may form, rilled first with serum, afterward with 
sero-pus. Very little inflammation is seen about these patches, and in 
most cases the intervening skin is normal. 

The favourite seat of the eruption is the face, especially about the 
chin, next the hands, the neck, the feet and legs, the forearms, and the 
scalp; it is rarely seen upon the abdomen, and never upon the back. 
There may be only half a dozen vesiculo-pustules, or from thirty to forty 
may be present. The smaller ones sometimes coalesce and form others 
of considerable size. Itching is never a prominent symptom, and in 
most cases it is absent altogether. 

The usual duration of impetigo contagiosa is two or three weeks; it, 
however, runs no regular course, and by continued auto-inoculation may 
last much longer than this. 

The studies of Gilchrist (Baltimore) point to a streptococcus of 
low virulence as the cause of this disease. European investigators, 
however, have with considerable uniformity found the staphylococ- 
cus pyogenes aureus in the vesicles. Impetigo contagiosa may occur 
in any child, but is seen most frequently in one who is poorly nour- 
ished. 

The diagnosis is not often difficult, and is made by the following 



890 DISEASES OF THE SKIN. 

features, viz., the occurrence of Beveral cases together, the isolated 
vesirulo-pustules situated upon the fare and hands, the slight itching, 
and the prompt cure by local measures only. The bullous form, how- 
ever, is frequently confounded with pemphigus; many cases in which 
the diagnosis o( pemphigus is made are examples of impetigo. 

Treatment. — This is simple and usually very effective. The crusts 
arc to be softened and removed by thoroughly washing the part with 
soap and water or a bichloride solution, after which the white precipitate 
ointment, combined with three parts of vaseline, should be applied. 



URTICARIA. 

Urticaria is a frequent disease in early life, and presents some fea- 
tures, particularly in infants and young children, which are quite dif- 
ferent from those seen in adults. This is due to the fact that papules 
and vesicles, and occasionally pustules, are associated with the wheals. 
As the wheals quickly subside, it frequently happens that the other 
lesions mentioned are the only ones present. This fact has given rise 
to considerable confusion in names, and the urticaria of infancy has 
been called lichen urticatus, urticaria papulosa, strophulus, etc. It is 
now pretty generally agreed that the clinical picture, which is a familiar 
one, belongs to a single disease, and that this is urticaria. 

The initial lesion is the wheal, but on account of the extreme suscep- 
tibility of the skin in young children, the process is more intense than 
in older patients, so that it may result in the formation of an inflam- 
matory papule or a vesicle. In a few hours the wheals may subside, and 
only the papules or vesicles remain, and without a good history the dis- 
ease may be a very obscure one. The papules and vesicles occur with 
greatest frequency upon the hands and feet, particularly the palms and 
soles. The more severe form of the disease in poorly nourished children 
is sometimes accompanied by a pustular eruption, and there may even 
be deep ulceration (ecthyma). The usual appearance of the eruption is 
a number of small inflamed red papules whose tops are covered with 
crusts, the result of scratching. The eruption may be limited to the 
extremities or it may be general. It is as a rule more severe in regions 
accessible to scratching. 

There is usually severe itching, which leads to loss of sleep, and often 
in this way the disease affects the general health of the child. The urti- 
caria of older children does not differ essentially from the same disease 
in adults. The alternation of urticaria and asthma is occasionally met 
with. 

The character of the eruption in urticaria and even its distribution 
strongly suggest scabies ; and unless one has had an opportunity to witness 
the development of the lesions, a differential diagnosis may be very difficult, 



SCABIES. 891 

as almost every lesion, exeepl the wheal, may be identical in both disea 

Other eases may resemble varicella. 

Urticaria in early life is most frequently the result of some disturb- 
ance in the digestive tract. Almost any sort of derangement may pro- 
duce it, the exciting cause varying with the patient. Exceptionally, it 

may result from other forms of irritation, such as dentition or intestinal 
worms. 

Treatment. — The milder forms of urticaria usually respond quickly to 
treatment ; but when it is severe and has existed for several weeks, it is 
one of the most troublesome and intractable skin diseases of childhood. 
The treatment is to be directed primarily toward the condition of the 
digestive organs. Children should be put upon a milk diet. The bowels 
should be kept freely open by calomel, a nightly dose of castor oil, or a 
morning dose of magnesia. If the urine is excessively acid and scanty, 
alkaline diuretics should be given. The drugs most useful for the indi- 
gestion with which urticaria is associated are salicylate of soda and nitro- 
muriatic acid, each of which is to be given after meals. 

All local causes of irritation, such as rough flannel underclothing, 
should be removed. The sleep may be so much disturbed as to require 
the use of trional or bromide and. chloral. Antipyrine and atropine are 
often useful; they may be given separately or in combination, and in 
moderately large closes. 

The local irritation and itching may be relieved by a very dilute 
solution of the subacetate of lead or carbolic acid, or by a mixture of 
vinegar, or the fluid extract of hamamelis, or bicarbonate of soda, and 
water. When pustules are present, the white precipitate ointment may 
be used, combined with four parts of vaseline; in the papular and 
vesicular forms, an ointment of ichthyol, one per cent strength. In 
many cases the improvement in the general health by the use of tonics, 
change of air, etc., will accomplish more than any measures directed 
especially to the relief of the urticaria. 

SCABIES. 

Scabies is a contagious disease due to the burrowing into the skin of 
the female acarus, with secondary lesions which result from scratching. 

The burrowing of the acarus is usually where the skin is thinnest — 
viz., between the fingers, on the flexor surfaces of the wrist, the axillae, 
and, in males, the genitals. It is not seen upon the face, except in in- 
fancy, when it may be infected by contact with the breasts of the mother. 
The lesion excited by the acarus is usually a papule or a vesicle, some- 
times a pustule. In some cases no evidences of inflammation are pres- 
ent, but in infants and young children they may be marked — pustular 
eruptions being frequent and often extensive, especially upon the hands 



892 DISEASES OF THE SKIN. 

and feet. The characteristic burrow is from one-fourth to one-half inch 

in length, and appears as a fine brown or black Line, at the end of which 
the acania may be discovered as a small white speck. The burrows are 
often difficult to find in infants. They are generally to be seen along 
the ulnar bonier of the hand and between the fingers. The intensity of 
the inflammatory lesions varies greatly in different cases; in some they 
are very few, while in others, particularly in delicate, cachectic, and 
neglected children, they are sometimes very severe, so that the skin of 
the affected part is nearly covered with pustules. These secondary lesions 
are due to infection by the streptococcus or staphylococcus. A pustular 
eruption upon the hands should always suggest scabies. The lesions 
which result from scratching may be found on any accessible portion 
of the body. There are usually at first linear, bloody marks, but after 
a time these may not be visible. In little children urticaria is often 
associated. 

The diagnosis of scabies is usually quite easy, as several children in 
a family are likely to be affected, particularly if they occupy the same 
bed. The diagnostic features of the eruption are the presence of papules, 
vesicles, or pustules, especially upon the hands, wrists, and genitals. A 
careful examination with a lens will usually disclose some of the char- 
acteristic burrows, or even the acarus. In infancy, scabies may be easily 
confounded with the vesicular form of urticaria, unless the development 
of the lesions has been observed. 

Scabies may always be cured, provided sufficient precautions are taken 
to prevent reinfection. This necessitates boiling or baking, not only the 
patient's clothes, but all the bedding as well. 

Treatment. — This should always be begun by a hot bath, in order to 
soften the epithelial scales about the burrows. The body should be thor- 
oughly scrubbed with soap and water, preferably with a nail-brush, the 
bath being continued for at least half an hour. It is well to do this at 
night. After the bath, the body is anointed with the parasiticide, which 
should be thoroughly rubbed into the skin, clean clothing applied, and 
the child put into a perfectly clean bed. In the morning the ointment 
may be washed off, but none of the clothing previously worn should be 
put on. This treatment is to be repeated on two or three successive 
nights, and if thoroughly done it will effect a cure. The ordinary sul- 
phur ointment is too irritating for use in little children, and one of the 
following may be substituted: Xaphthol, 15 parts; creta preparata, 10 
parts; vaseline, 100 parts (Kaposi); or, precipitated sulphur, 1 part; 
balsam of Peru, 1 part ; vaseline, 8 parts ; or the simple balsam of Peru 
may be applied without dilution. After the use of the parasiticide there 
is generally required, for a few days, some soothing application like those 
mentioned in the chapter upon Eczema. 



TINEA TONSURANS— KING-WORM OF THE SCALP. gQ3 

TINEA TONSURANS— RING-WORM OF THE SCALP. 

Ring-worm of the scalp is a very frequent disease in institutions for 

children, often occurring as an epidemic. According to Crocker, the 
primary lesion consists in a red papule surrounding a hair, which soon 
increases to a small circular patch; this spreads at its outer margin, 
gradually increasing in size until it is from one to two inches in diameter, 
but rarely larger than this. Sometimes several of the patches coalesce. 
These affected areas always have rounded borders, and are sharply out- 
lined. Here the hairs are \ery brittle, and often broken off close to the 
scalp, so that the area may appear to be bald. Where they have not fallen 
off, the hairs have lost their lustre. The stumps of the broken hairs point 
in all directions. 

The fungus which produces the disease is the trichophyton tonsurans. 
It penetrates -the shaft of the hair, both the spores and the mycelium 
being seen under the microscope. The spores are present in great num- 
bers in the hair, but the mycelium is most abundant in the scales. The 
amount of inflammation found in the diseased areas varies much in the 
different cases. There may be only a scaliness of the scalp, or a forma- 
tion of pustules in the hair follicles, the hairs loosening and falling out 
in consequence. In young infants, where the hair is scanty and thin, the 
disease resembles tinea circinata — i. e., it is superficial, and the hair fol- 
licles are often not involved. Children of all ages are liable to tinea 
tonsurans. It flourishes particularly in institutions and in those children 
who are dirty and poorly cared for. 

The diagnostic feature of the disease is the presence of scaly patches, 
with loss of hair. The patches are usually circular, and by examination, 
with a lens the stumps of broken hairs are seen all over the diseased 
area. By a microscopical examination the fungus is discovered. In 
typical cases the diagnosis is easy if the process is at all advanced, but 
there are many atypical forms and many mild cases where the recogni- 
tion of the disease is difficult. The symptoms are often masked by the 
inflammatory conditions present. The disease may be confounded with 
seborrhcea; but in the latter the lesion is diffuse, never sharply defined; 
there is general thinning of hair over the scalp, and never the stumpy, 
broken hairs. Psoriasis has points of resemblance, but it is usually found 
on other parts of the body, especially the knees and elbows, and upon the 
scalp the patches are more numerous and smaller. In eczema the loss of 
hair in circumscribed patches is never seen, nor are the broken stumps. 

Tinea tonsurans is always curable, provided the patient can be kept 
under close surveillance, and treatment thoroughly carried out. There is 
no tendency to spontaneous recovery. In a recent case, treatment must 
usually be continued for one or two months, and in chronic cases from 
six months to one year, with the closest watchfulness. 



894 DISEASES ov THE SKIN. 

Treatment. Thegreal difficulty in treatmenl is to get the parasiticide 
deeply enough into the scalp to reach the fungus, since this is often at 
the very bottom o\' the hair follicles. As a first step, the hair should be 

rut short all over the patch and for at least an inch beyond it; this is 
ssary in order to gel at the diseased part and to detect new foci of 
infection early — if possible before the fungus has extended deeply into 
the follicles. The parasiticide should be applied not only upon but 
around the patch, and the entire scalp should be washed thoroughly two 
or three times a week. To prevent the disease spreading, all the scales 
are to he kept softened by the use of carbolic soap. The hair should not 
he brushed, as this tends to scatter the spores and spread the disease. 
All patients, while under treatment, should wear a cap of muslin or oiled 
silk, or one lined with paper, in order to prevent infecting others. In 
institutions, affected children should invariably be isolated. 

To destroy the fungus almost every germicide on the list has been 
advocated at one time or another, which proves that the disease is a very 
obstinate one, and that no one application is invariably successful. 
Those which have the sanction of the widest use are the tincture of iodine, 
the bichloride, white precipitate, and oleate of mercury, kerosene, creo- 
sote, and croton oil. As a vehicle for ointments, adeps lanae (lanoline) 
is greatly to be preferred to vaseline or lard. Most of the germicides 
mentioned are used in the strength of one to five per cent, according to 
the age of the child and the irritability of the scalp. In an epidemic 
of ring-worm in the New York Infant Asylum the following combination 
of bichloride and kerosene proved extremely satisfactory : ten grains of 
the bichloride were dissolved in alcohol, and to this were added two and 
a half ounces each of olive oil and kerosene. 

Epilation is necessary in many cases as an accessory to the application 
of germicides, particularly in older children. 



CHAPTER VI. 
DISEASES OF THE EAR. 

ACUTE OTITIS. 

Otitis is a frequent affection during infancy and early childhood, 
attacks usually occurring in the cold season. Of all the inflammatory 
conditions which may be met with in early life, there is perhaps none 
which more frequently gives rise to obscure febrile symptoms than this. 

Etiology. — Acute otitis is, as a rule, a secondary disease, and is gen- 
erally preceded by some infectious process in the rhino-pharynx. The 
usual avenue of infection is through the Eustachian tube. 

The most severe forms of otitis usually follow scarlet fever, epidemic 



ACUTE OTITIS. 895 

influenza, measles, diphtheria, or pneumonia. The entrance of fluids 
through the Eustachian tube from the nasal (louche or nasal Byringing 
may cause acute otitis. It sometimes results as an extension of inflam- 
mation from meningitis, especially the cerebro-spinal form. 

The micro-organisms concerned in the production of acute otitis 
vary somewhat with the condition of which it is a complication. In the 
order of frequency there are found the staphylococcus aureus, the pneu- 
mococcus, the streptococcus, and the influenza bacillus. Mixed infect ions 
are very common. In cases complicating diphtheria, the EQebs-Loeffler 
bacillus may be found with any of the forms mentioned, or may occur 
alone. In chronic cases any of the pyogenic organisms may be present, 
and not very infrequently the tubercle bacillus. 

Lesions. — The ordinary course of events in the pathological process is, 
first, acute hyperemia and swelling of the mucous membrane of the rhino- 
pharynx, which extends into the Eustachian tube, causing obstruction 
more or less complete. The inflammatory process may be limited to the 
tube, or it may extend to the mucous membrane lining the middle ear. 

There are two varieties of acute inflammation of the middle ear : ( 1 ) 
The catarrhal form, which usually accompanies simple catarrh of the 
rhino-pharynx or complicates measles. This is an inflammation of the 
mucous membrane merely, and its products are serum and mucus or 
muco-pus. It is not usually accompanied by great pain or followed by 
serious consequences. It is generally confined to the lower part of the 
tympanic cavity, and is the form most frequently seen in infants. (2) 
The purulent or phlegmonous form, which affects older children prin- 
cipally. This is a much more serious inflammation, and is often ex- 
cited by the infectious catarrh of scarlet fever, diphtheria, or epidemic 
influenza. In this variety micro-organisms find their way into the mid- 
dle ear in great numbers, and set up an inflammation of a more or less 
virulent type, which may involve not only the mucous membrane lining 
the tympanum, but also the cellular tissue in the upper part of the tym- 
panic cavity. The lining membrane of the mastoid cells is involved 
in many, if not all, of the cases. 

The catarrhal form of inflammation frequently subsides in a few 
days with proper treatment, the only result being a slight deafness, 
which is temporary. The phlegmonous form causes a stoppage of the 
Eustachian tubej rupture or sloughing of the tympanic membrane, and 
discharge of the products of inflammation, or rarely pus finds an outlet 
by burrowing between the cartilages. The inflammatory process may 
extend to the bones, causing necrosis of the ossicles or the bony walls of 
the tympanum. The remote results are periostitis and necrosis of the. 
petrous bone, pachymeningitis, infectious thrombosis of the lateral 
sinus, general purulent meningitis, and cerebral abscess. These will be 
considered under Complications. 



896 



DISEASES ov THE EAR. 



Symptoms. These are usually few in number, but present great varia- 
bility as regards their combination and intensity. The two most con- 
stant symptoms are pain and fever. In a typical case in an infant, there 
is generally at the beginning some discharge from (lie nose, slight con- 
gestion of the pharynx and tonsils, and a temperature of 100° to 102° F. 
There is nothing characteristic about this catarrh. After two or three 
days the objective symptoms subside, but the infant continues to be rest- 
less, worries much of the time, wakes frequently at night with a start, 
nurses poorly, and the temperature remains elevated, usually from 100° 
to 103° P. (Fig. ITS). The infant seems decidedly ill, and yet no very 
definite symptoms are present. Sometimes there is marked tenderness 
about the ear, and the child refuses to lie upon the affected side, or shows 
signs of pain when the ear is touched. After a week or ten days spon- 
taneous rupture of the drum membrane takes place, and subsidence of the 
constitutional symptoms follows. In some cases there is seen only a high 
temperature, ranging from 101° to 104° F., which persists for several 



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Fig. 178. — Temperature Chart of Acute Otitis Following Influenza, in a Child 

Three Years Old. 



days without outward evidences of pain or other signs of inflammation, 
and the discharge is the first symptom which leads the plrysician to sus- 
pect disease of the ear. In other cases there is marked dulness, apathy, 
anorexia, and sometimes nausea and vomiting, but for several days 
no evidence of pain; the temperature may be but little elevated. 
Thus, in most of the attacks seen in infancy, pain is not very marked, 
and it is this which so often leads to the great obscurity of the 
symptoms. 

In older children the symptoms are more characteristic. Pain is 
usually sharp and severe, and is complained of early in the attack. The 
temperature is nearly always elevated two or three degrees, and occa- 



ACUTE OTITIS. 



897 



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sionally it is 103° or 104° F. (Fig. 179), with severe headache, extreme 
restlessness, and even delirium or convulsions, so that meningitis may be 
suspected. 

The inflammation does not neces- 
sarily go on to suppuration and rup- 
ture. There are even more frequently 
seen, accompanying ordinary head-colds 
or mild attacks of influenza, cases in 
which the pain is quite severe for 
twenty-four or thirty-six hours, and 
accompanied even by a moderate ele- 
vation of temperature, and yet which 
rapidly subside without further symp- 
toms. 

In infants suffering from malnutri- 
tion or marasmus, otitis often comes 
on without any objective symptoms, 
the first thing noticed being the dis- 
charge. 

Of all the symptoms, fever is the 
most constant, and is present in all 
cases except those just mentioned. The 
usual range of temperature is from 
100° to 102° F.; exceptionally it may 
be from 103° to 105° F. The course 
of the temperature is irregular. After spontaneous rupture or in- 
cision of the drum membrane the temperature usually falls, but 
often not immediately. Pain is more marked in older children than in 
infants — first, because in the latter the drum membrane is not so firm, 
yields more readily, and ruptures earlier; and, secondly, because the in- 
flammation is usually of the catarrhal and not the phlegmonous type. 
Tenderness is sometimes elicited by pressure, especially just in front of 
the external auditory meatus ; there may be increased sensitiveness of all 
parts of the ear and even of the whole side of the head; but no reliance 
should be placed upon the absence of such symptoms in excluding otitis. 
Children often complain of noises in the ear. Cerebral symptoms are in- 
frequent, and occur chiefly in cases not receiving proper early treatment ; 
they may indicate meningeal congestion, or, less frequently, localised 
meningitis or thrombosis. 

In secondary otitis, especially when complicating severe scarlet fever, 
diphtheria, measles, or typhoid fever, all subjective symptoms are fre- 
quently wanting; unless the ears are examined the disease may be over- 
looked until rupture has taken place. 

The local appearances in the early stage are marked redness and con- 
58 



Fig. 179. — Temperature Chart of 
Acute Otitis Aborted by Early 
Paracentesis. Boy nine years old ; 
attack followed a mild catarrh; se- 
vere pain in both ears began in after- 
noon of second day. Both drum 
membranes found acutely congested 
and bulging; incision followed by 
free haemorrhage and immediate re- 
lief of pain. No suppuration oc- 
curred; patient well on fifth day. 



SOS DISEASES OF THE EAR. 

gestion; later there is distincl bulging. If perforation has taken place, 
its site may or may not be visible, bul its existence may be assumed if 
bubbles of air are Been deep in the canal, and if much mucus or pus is 
present, as inflammation of the external canal seldom causes a discharge. 

The pus sometimes burrows between the cartilages and escapes externally 
behind or at the side of the ear. In the catarrhal form the discharge is 
at first sero-mucus and quite profuse; later it is purulent. In the phleg- 
monous form it is always purulent, and liable to a sudden arrest with 
an increase in the constitutional symptoms. 

Diagnosis. — Otitis in infancy is frequently obscure, because the pa- 
tient is too young to direct attention to the seat of pain, or because the 
pain is slight or absent. The temperature is almost invariably elevated, 
and the usual problem presented is to discover a cause for this fever. 
The examination of the ears with a speculum should be done as a matter 
of routine in all children with fever, especially those in whom the cause 
of the fever is not perfectly clear. Otherwise many cases will be over- 
looked. A. leucocytosis of 15,000 to 20,000 is almost invariably found. 
Local tt derness, deafness, or noises in the ears are significant when 
present, but are often wanting. Otitis is so common a cause of high 
temperature in infants during the cold season, that one should always 
have it in mind. 

Complications and Sequelae. — Eemote consequences are most likely 
to be seen in cases following scarlet fever, probably because of their 
severity, particularly when early treatment has been neglected. 

Mastoiditis. — This is the most frequent complication of acute otitis. 
In infancy the mastoid process is small and contains but a single- cavity, 
the mastoid antrum, which communicates directly with the vault of the 
tympanum. It is probable that in every severe case of acute suppurative 
otitis there is some pus in the antrum. This is usually discharged into 
the middle ear after the tympanic membrane is incised or ruptures spon- 
taneously. The principal cause of mastoid involvement is want of proper 
early treatment in acute otitis, particularly the practice of allowing these 
cases to take their natural course instead of securing early drainage by 
incision of the drum membrane. 

The important symptoms of acute mastoiditis are fever, mastoid ten- 
derness, and swelling. If mastoiditis develops rapidly after acute otitis 
the temperature may be high — 103° to 105° F., and the leucocytosis is 
somewhat greater; if it develops gradually and appears late the tem- 
perature may be scarcely above 100° F. Abrupt cessation of an ear dis- 
charge should always arouse suspicion. It is always difficult to de- 
termine the presence of a slight amount of mastoid tenderness, but 
persistent tenderness of one side only is significant. It is often most 
marked close behind the auricle just over the antrum. The early swell- 
ing is due to oedema; later there may be an accumulation of pus. Post- 



ACUTE OTITIS. 899 

auricular abscess causes a very characteristic Bwelling, the ear Btanding 

out from the head. It is usually due to spontaneous rupture through 
the outer bony wall just over the antrum; it may occur where there has 
been no discharge from the ear. It is a frequent result of Bevere ca 
of acute mastoiditis not operated upon, especially in young children. 

The characteristic otoscopic appearances of acute mastoiditis are : 
bulging of ShrapnelPs membrane and drooping of the upper posterior 
wall of the external auditory canal. 

Meningitis. — This is very rare in infants, but is more common in 
older children. There may be a localised pachymeningitis with the for- 
mation of pus — an epidural abscess — or, less frequently, general purulent 
meningitis. It may be secondary to other lesions, such as thrombosis of 
the lateral sinus, or the rupture of a cerebral abscess, but is usually due 
to infection through the roof of the tympanum, or along the internal 
auditory meatus. Meningitis may occur either with acute or chronic 
cases. Its symptoms are those of a severe acute meningitis ; its duration 
is short ; its termination almost invariably in death. 

Cerebral Abscess. — This is due to a direct extension of the infection 
from the bone, veins, or dura mater. In about two-thirds of the cases 
the abscess is in -the temporo-sphenoidal lobe. The next most frequent 
seat is the lateral lobe of the cerebellum. Korner states that disease of 
the mastoid and middle ear leads to cerebral abscess, and disease of the 
labyrinth to cerebellar abscess. Abscesses may be complicated by throm- 
bosis or by meningitis. They are often latent until just before death, 
which more frequently occurs from the development of purulent menin- 
gitis than from any other cause. They are rare except in otitis of long 
standing. 

Thrombosis of the lateral sinus may be simple or septic. In the 
former there is occlusion of the vessel by a fibrinous clot; in the latter 
there are in addition, micro-organisms. 

Simple thrombosis causes no important symptoms. Septic throm- 
bosis is relatively infrequent and causes very marked and severe symp- 
toms. It follows operation upon the mastoid, or occurs as a complication 
of mastoiditis quite apart from operation. The temperature is usually 
of a high and widely fluctuating type, and there may also be chills. In 
some cases the constitutional symptoms, except fever, may not at first be 
severe, but may suddenly become very grave. Marked cerebral symptoms 
often develop rapidly, and death may follow in from twelve to twenty- 
four hours. At autopsy there may be found a soft broken-down clot in 
the sinus, which may extend into the jugular. It may be followed by 
secondary lesions of a general pyaemia, or by localised or general menin- 
gitis. Blood cultures usually give positive information. 

The labyrinth is infrequently involved, although cases are recorded 
by Pye, Phillips, and others, in which the necrosis and discharge of the 



900 nisi: asks of the ear. 

entire labyrinth has occurred after scarlet fever. In most of these cases 
the deafness was complete, and in Beveral vertigo was present. 

Facial paralysis rarely occurs in the acute cases, but accompanies a 
considerable proportion of the chronic ones. It is especially seen in the 
tuberculous variety. It is due to an extension of the inflammatory proc- 
ess from the bone to the seventh nerve, where it passes through the canal. 
The symptoms are those of ordinary peripheral facial palsy. 

Treatment. — Something may be done in the way of prophylaxis. It 
is of the first importance to secure a normal condition of the mucous 
membrane of the naso-pharynx by the removal of enlarged tonsils, ade- 
noids, etc. The occasional attacks of earache accompanying these con- 
ditions are pretty sure to be followed by more serious trouble unless they 
are relieved. Whether during attacks of measles or scarlet fever, much 
can be done to prevent otitis, is still a mooted question. Personally I 
believe the risks of infection of the middle ear when judicious nasal 
syringing is employed are less than when nothing is done to cleanse 
the rhino-pharynx. 

The medical treatment of acute otitis aims at the relief of pain and 
arrest of the inflammation. If the case is seen in the early stage the 
introduction of a few drops of a solution of adrenalin into the nostrils 
and ears and repeated every two o r three hours, will sometimes abort 
an attack. This may be aided by free catharsis and the application of 
dry heat or frequent syringing of the ears with a saline solution as hot 
as can be borne. Xeither oil nor laudanum should be dropped into the 
ear as is so often done in domestic practice; but there is no objection 
to a few drops of a four-per-cent solution of cocaine, or a nve-per-cent 
solution of carbolic acid, either of which may relieve intense pain. If 
the child is not soon comfortable, an opiate should be given which may 
not only relieve pain, but may have a favourable influence upon the in- 
flammation. 

A continuance of pain in spite of these measures, with an increas- 
ing temperature, calls for operative interference. But a more reliable 
guide is the appearance of the drum membrane. If in addition to these 
symptoms there is mastoid tenderness immediate paracentesis of the 
drum membrane is imperative. An early incision is usually followed by 
a discharge of blood only; but tension is relieved, pain disappears, and 
the inflammation often quickly subsides without the formation of pus. 
(See Fig. 179.) Much suffering is thereby avoided; the wound rapidly 
heals, and much less damage is done than by allowing the disease to go on 
to a spontaneous rupture. Later incision may be required either for the 
relief of pain or for the evacuation of pus to prevent, if possible, the dis- 
ease from spreading to the bony parts. The advantages of early paracen- 
tesis in acute otitis can hardly be overstated. Properly performed, it is 
free from risk, causes little or no shock, and should be advised in many 



ACUTE OTITIS. 901 

cases even in which the indications are not so clear as those above described. 
J favor incising the drum membrane in cases of doubl nil her khan waii 
ing for more definite indications with the attendant risks of delay. 

In the secondary- otitis of scarlet fever, measles, and diphtheria, the 
indications for paracentesis are usually to be derived from the appear- 
ance of the drum membrane alone, other symptoms being absent or 
masked by the primary disease. 

After incision or spontaneous rupture of the drum membrane the 
ear should be syringed every two or three hours with a warm solution 
of bichloride (1 to 10,000), or a saturated solution of boric acid, or 
simply with a sterile salt solution. A bulb ear-syringe of soft rubber 
or a fountain syringe may be used. 

In most cases the discharge ceases in from one to three weeks ; should 
it continue longer, some measures for checking it may be used. The use 
of a few drops of a 1 to 3,000 solution of bichloride in sixty-five per 
cent alcohol after syringing is of some value. It should be used with 
a medicine dropper. When the discharge has become foetid, syringing 
once a day with a solution of peroxide of hydrogen (1 to 2) is often 
useful. A persistent discharge often depends upon the fact that the 
child's general condition is poor, and improvement in this is more im- 
portant than any variation in local treatment. 

When symptoms pointing to acute mastoiditis are present, early 
free incision of the drum membrane is indicated, and a mastoid ice- 
bag should be applied continuously for thirty-six or forty-eight hours. In 
addition, in older children, the artificial leech may be placed over the 
antrum or the mastoid tip. With these measures the inflammation often 
subsides. Regarding operation upon the mastoid, my own belief is that 
it is now performed too frequently and with insufficient indications, 
especially in infancy and early childhood. The operation is a serious 
one, and at this age its immediate risks are considerable. I have per- 
sonally known of a number of deaths directly connected with it, and of 
others occurring at a later period, where the child was worn out by the 
long after-treatment, dying perhaps from some intercurrent disease or 
from exhaustion. On the other hand, the dangers to which patients are 
exposed who are not operated upon have, I think, been greatly exag- 
gerated. . In my own experience, meningitis, sinus thrombosis, and 
cerebral abscess do not occur in anything like the proportion of cases 
that the surgeons would have us believe. 1 

While I fully appreciate the value of the operation, and am quite 
sure that lives are often saved by its timely performance, I would in- 

1 The records of the New York Foundling Hospital, with a resident population of 
about 800 infants and young children, showed 573 cases of acute otitis in five years 
(1900 to 1904 inclusive). During this period there were three extensive epidemics of 
measles with a total of 1,034 cases; 166 cases of scarlet fever; 578 cases of diphtheria; 



902 DISEASES OF THE EAR. 

sisi that it be done only with very positive and clear indications. In 
infants. Localised tenderness is difficult to determine; and fever after 
acute otitis may be due to many other conditions. In very young pa- 
tients we should therefore insist upon other symptoms before deciding 
to operate. The risks of waiting for clearer indications are, I believe, 
much less than those attendant on unnecessary operation. Often the 
cause of the temperature is found in the lungs; and not very infrequently 
a moderate pulmonary congestion or bronchitis becomes a pneumonia 
as a consequence of the prolonged anaesthesia necessary for the operation. 
With infants therefore in case of any doubt, as to diagnosis or the 
progress of the case, one should invariably decide against operation, or 
at least for postponement. With older children, however, conditions 
are somewhat different; diagnosis is easier and the operative risk much 
less. 

The treatment of chronic otitis and of the associated conditions is 
largely surgical, and belongs to the specialist; but it is extremely im-- 
portant that the general practitioner should be familiar with their symp- 
toms, and realise the danger from these neglected cases, not only to the 
function of hearing, but also to life itself. The essential thing in treat- 
ment is that the operation should be thorough enough to secure free 
drainage, and to permit thorough cleansing of the parts. Too much 
can not be said against the expectant treatment of these cases, or against 
the practice of prolonged poulticing. 

and 1,505 cases of pneumonia. With the 573 cases of otitis, acute mastoiditis was 
recognised and recorded in but 17 patients. It is not improbable that other mastoid 
inflammations were overlooked. In this institution, however, nearly every fatal case 
comes to autopsy, and if an unrecognised mastoiditis had led to a fatal result the 
autopsy records should show it. In the five-year period, 900 autopsies were made. 
There was no instance recorded of abscess of the brain following otitis. There were 
but two examples of acute meningitis following otitis with mastoiditis; but there were 
14 cases of acute meningitis secondary to other conditions — pneumonia, 10; to peri- 
carditis, 2; to empyema, 1; to diphtheria, 1. During the period mentioned there 
were 11 mastoid operations performed in the hospital, with 6 recoveries and 5 deaths, 
all from causes directly connected with the operation. 

If mastoiditis follows otitis, complicating the acute infectious diseases of early 
childhood as often as has been claimed, we must admit that a very large proportion 
of the patients may get well without operation. 



SECTION IX. 
THE SPECIFIC INFECTIOUS DISEASES. 

Accurate classification of the infectious diseases is at the present 
time impossible, but there are two quite distinct groups into which, with 
one or two exceptions, those here considered may be placed. 

The first group includes scarlet fever, measles, rubella, and varicella. 
The nature of the specific poison in each of these is as yet unknown. 
They are, strictly speaking, contagious; for it is practically certain that 
any of them may be contracted by proximity to a person suffering from 
the disease, without actual contact. In no one of these diseases is the 
poison given off in a single definite discharge, and in no one is there a 
characteristic visceral lesion. These peculiarities, together with the fact 
that thus far the poison of each of these diseases has resisted all attempts 
at isolation, render it not improbable that the exciting cause in each is 
some other variety of micro-organism rather than a bacterium. 

In the second group may be placed diphtheria, pertussis, influenza, 
typhoid fever, and tuberculosis, in each of which the specific poison is a 
known form of bacterium. Each of these diseases, except pertussis and 
influenza, is associated with definite and characteristic visceral lesions. 
The poison is discharged from the body in a certain well-understood 
manner from the tissues which are affected by the disease, and in no 
other way. 

Syphilis and malaria have not been included in either of the above 
groups. They belong in a class by themselves. 



CHAPTER I. 

SCARLET FEVER. 
(Scarlatina.) 

Scarlet fever is an acute, contagious, self-limited disease, one attack 
usually protecting the individual through life. The period of incuba- 
tion is usually from two to four clays; that of invasion, from twelve to 
twenty-four hours; that of eruption, from four to six days; that of 
desquamation, from three to six weeks. The disease may be communi- 
cated at any time from the first symptom of invasion throughout des- 

903 



904 THE SPECIFIC INFECTIOUS DISEASES. 

quamation, and oven during the existence of purulent discharges from 
the Qose or other mucous or serous membranes. It is usually ushered 
in by vomiting, fever, and sore throat, and is characterised by an ery- 
thematous rash appearing first upon the neck and spreading rapidly over 
the entire body, lis chief complications are otitis, adenitis, and mem- 
branous inflammations of the pharynx, which frequently extend to the 
nose, rarely to the larynx. The most important sequelae are otitis and 
nephritis. The constancy of the throat infection in scarlet fever strongly 
points to the pharynx as the point of entry of the infection. 

Etiology. — Analogy leads to the belief that scarlet fever is due to a 
micro-organism, but as yet its nature has not been discovered. The 
complications are usually associated with the development of a strepto- 
coccus. Some have gone so far as to claim that a streptococcus is the 
cause of the disease. From present knowledge, however, it appears rather 
to play the role of a secondary or accompanying infection, for the devel- 
opment of which the mucous membranes of a person suffering from 
scarlet fever seem to afford most favourable conditions. To the strepto- 
coccus may be ascribed the membranous inflammations of the tonsils 
and pharynx, the otitis, the inflammation of the lymph nodes and the 
cellular tissue of the neck, and probably also the nephritis, endocarditis, 
pneumonia, and joint lesions. In many of the above conditions the 
streptococcus is associated with other pyogenic germs, and in some cases 
with the diphtheria bacillus. The exact role played by the strepto- 
cocci and by the virus of scarlet fever in these complications is still a 
matter of disjDute, the probabilities being that some are due to one and 
some to both of these infective agents. 

Predisposition. — The susceptibility of children to the scarlatinal 
poison is much less than to that of measles ; still, it is much greater than 
that of adults. Billington (New York) records observations made in 
twenty-six families living in tenements where little or no attempt at 
isolation was made. In these families there occurred forty-three cases 
of scarlet fever ; but f orty-seven other children, although unprotected by 
previous attacks and constantly exposed, did not contract the disease. 

Johannessen reports that of 185 children under fifteen years who 
were exposed, twenty-eight per cent contracted the disease; while of 314 
adults, only five per cent contracted the disease. It may be stated that, 
approximately, not more than one-half of the children exposed take the 
disease. The susceptibility is not great in early infancy, but it increases 
until about the fifth year, after which it steadily diminishes. Both sexes 
are equally liable to scarlet fever. Epidemics are more frequent in the 
fall and winter than in summer, and cases occurring in the cold months 
are apt to be more severe. Whitelegge, in 6,000 cases, found the highest 
mortality in the month of October; and in Caiger's report of 1,008 cases 
this was also the month showing the greatest mortality. 



SCARLET FEVER. 905 

Incubation. — Of 113 cases 1 in which the period of incubation could 

be accurately determined, it was as Follows: 

8 days 2 cases. 

5 

1 case. 

1 " 

1 " 

113 cases. 



24 hours or less 6 cases. 

2 days 

3 

4 

5 

6 

7 



15 


u 


9 


28 


(t 


11 


25 


ti 


14 


6 


" 


21 


15 


u 




8 


(( 





Tims in eighty-seven per cent of these it was between two and six 
days, and in sixty -six per cent between two and four days. Speaking 
generally if, after exposure, a week passes without symptoms, the chances 
of infection are very small. A short incubation is more frequently seen 
in severe than in mild cases. 

Mode of Infection. — The chief source of infection is the patient hi in- 
self. It is somewhat doubtful whether the poison of scarlet fever can 
be conveyed by the breath, but it surely is by discharges from the mucous 
membranes involved, probably by the scales during desquamation, and by 
all the excretions of the patient — urine, faeces, and perspiration. Infec- 
tion often takes place from the carpets or furniture of the sick-room, 
and from the clothing of the patient. In a city, the bedclothing, while 
airing in the window, has been known to convey the disease to an adjoin- 
ing house. Instances are recorded of the spread of scarlet fever by the 
washing of infected with other clothing. Toys or books may be carriers 
of the disease. A bouquet of flowers sent from a sick-room to an insti- 
tution, in one instance proved a vehicle of infection. Cats, dogs, and 
other domestic animals are known to have conveyed the disease. Scarlet 
fever is sometimes spread by food, particularly by milk. 

The transmission of the disease through a third person is not fre- 
quent, but numerous instances of it are on record. The persons most 
likely to carry it are the nurse and the physician. Physicians have in 
many cases carried scarlatina to their own children, but only when there 
had been very direct contact with the patient, and w T here the interval 
before seeing the second child was short. The clothing of the nurse 
may be almost as infectious as that of the patient. The transmission of 
the disease by one who, although living in the house, does not come in 
contact with the patient is extremely improbable. An instance is re- 
corded in Allbutt where scarlatina was transmitted through two healthy 
persons. 

Duration of the Infective Period. — There is no evidence to show that 
the disease is communicable during the period of incubation. It is 

1 Part of these are from personal observation, but the great majority are isolated 
cases scattered through medical literature, occurring under circumstances which made 
it possible to determine the exact length of the incubation period. 



90() THE SPECIFIC [NFECTIOUS DISEASES. 

slight lv contagious from the beginning of invasion, before the rash 
appears, [nfection appears to be most active at the height of the febrile 
period — from the third to the fifth day — and, next to this, during the 
stage of active desquamation. 

In simple cases, the average duration of the contagious period may 
be placed at sis weeks, or until desquamation is complete. However, 
physicians generally have been accustomed to place too much stress upon 
the danger from the scales, and too little upon that from the discharges 
from the mucous membranes. Early infection comes chiefly from the 
throat, nose, or possibly the breath. Late infection may arise from a 
purulent otitis, rhinitis, chronic pharyngitis, suppurating glands, em- 
pyema, and possibly also from the urine in nephritis. The infectious 
nature of these purulent discharges has not been sufficiently recognised. 
It is possible for them to convey the disease during a period of several 
months. One case is recorded in which scarlatina was communicated 
through a purulent nasal discharge after eleven weeks; another in which 
the opening of a post-scarlatinal empyema in a surgical ward was fol- 
lowed by an outbreak of scarlet fever. 

In winter especially, a chronic pharyngeal catarrh may long contain 
the germs of infection. Ashby found, on careful investigation, that from 
two to four per cent of patients discharged from a scarlet-fever hospital 
subsequently conveyed the disease. There is particular danger from a 
child who has recently had the disease sleeping with other children. Line 
records a case in which this was the means of conveying the disease after 
fourteen weeks, and when the patient had been considered perfectly well 
for three weeks. It is impossible to say that at any specified time ab- 
solute safety exists. All patients before being discharged from a hospital 
or released from quarantine in private practice, should be carefully ex^ 
amined as to the condition of the mucous membranes, and quarantine 
continued as long as catarrhal inflammations are present. The poison 
of scarlatina clings more tenaciously to clothing, upholstery, and apart- 
ments than that of any other infectious disease, possibly excepting tuber- 
culosis. Authentic cases are on record in which more than a year had 
elapsed between the first and second cases, where the source of infection 
seemed certain. 

Lesions. — The only characteristic lesions of scarlatina are those of 
the skin and the mucous membranes of the mouth and throat. The skin 
is the seat of an acute dermatitis of variable depth and intensity. There 
is first acute hyperaemia, followed by an exudation of serum and cells in 
the corium, especially about the blood-vessels and hair follicles. There 
results a death of the epidermis which is thrown off in the desquamation. 
The mucous membrane of the mouth, tongue, and throat is the seat of 
a catarrhal, membranous, or gangrenous inflammation which rarely in- 
vades the larynx, but very frequently the middle ear and nose. The entire 



SCARLET FEVER 907 

oesophagus is often the seat of an intense congestion. From the ear the 
infection may extend to the mastoid cells, the meninges, or the brain, 
and from the nose to the accessory sinuses, particularly the antrum 
of Highmore. All the lymph nodes about the Deck may be involved, 

the infection ending in eell-hyperplasia, suppuration, or oecr 
The cellular tissue of this neighbourhood may also become infiltrated, 
this being followed sometimes by suppuration and occasionally by 
gangrene. 

The most constant change throughout the body, according to Pearee, 
is hyperplasia of the lymphoid tissue, which is seen everywhere. The 
other lesions are degenerations due to the scarlatinal poison alone, 
in conjunction with the various forms of secondary infection, or to 
the latter alone. The most important are : fatty degeneration of the 
heart ; areas of focal necrosis in the liver ; acute degeneration of the 
kidney or acute diffuse nephritis; proliferation of the cells of the 
Malpighian bodies of the spleen; broncho-pneumonia, gangrene, or 
abscess of the lung; pleurisy, which is often purulent; endocarditis, 
pericarditis ; abscesses in the cellular tissue and inflammation of the 
joints. These visceral changes will be considered more fully under 
Complications. 

Symptoms. — Invasion. — As a rule, the invasion of scarlet fever is ab- 
rupt, the symptoms at the onset usually being directly in proportion to 
the severity of the attack. In the majority of cases there is vomiting, 
a rapid rise in temperature, and soreness of the throat. Often the vomit- 
ing is repeated; it is frequently forcible, and without nausea. In severe 
cases the rise in temperature is very rapid, to 104° or 105° F. ; in the 
mildest cases it may not be above 101 c F. A child may complain of sore- 
ness of the throat, or the throat symptoms may be entirely objective. In 
most severe cases, there is a uniform erythematous blush covering the 
pharynx, tonsils, and fauces, but on the hard palate there are minute 
red points. The appearance of this is usually coincident with the rise 
in temperature. Occasionally membranous patches may be seen upon the 
tonsils the first day. but not generally before the third or fourth day. In 
mild cases the throat shows only a very moderate congestion. Severe 
cases are sometimes ushered in by convulsions, especially in very 
young children. Diarrhcea is not uncommon in summer. There 
general prostration, which is directly proportionate to the lwight of the 
fever. 

Eruption. — This usually appears from twelve to thirty-six hours after 
the first symptoms of invasion : exceptionally, not until the third or even 
the fifth day. A later appearance than this is somewhat doubtful, for 
the rash not infrequently recedes and reappears, having been overlooked 
in the first instance. In 108 cases observed in the Xew York Infant 
Asylum, the duration of the rash was as follows : 



908 THE SPECIFIC INFECTIOUS DISEASES. 

Two days or less 5 cases. 

Three to seven days 81 " 

Eighl to eleven days 16 " 

Over eleven days 4 " 

Recurring 2 " 

Those stat i sties are confirmed by the observations of most writers, 
that the rash lasts from three to seven davs. The full development of 
the rash is generally seen in from twelve to twenty-four hours from its 
first appearance, and not infrequently the whole body is covered in the 
course of four or five hours. Very rarely its extension is so slow that 
it is two or three days before the body is covered. Its first appearance 
is almost invariably upon the neck and chest. In the cases of moderate 
severity the typical rash is seen. Its colour is red rather than scarlet, and 
on close inspection it is seen to be made up of very minute points upon 
a reddish ground giving the appearance of a uniform blush ; or the back- 
ground may be wanting and only the punctate eruption shows. These 
points are the papillae of the skin and hair follicles. The rash usually 
covers the entire body except the face. This may be the seat of an 
ordinary flush. Even in cases with intense eruption the central part of 
the face usually escapes, though elsewhere the eruption may be as bright 
as upon the body. There is often a peculiar pallor about the mouth 
which is characteristic. The appearance of the eruption in dark-skinned 
races is much modified and often difficult of recognition. In the negro the 
palms and soles may be the only places where the eruption can be distin- 
guished. Here may be seen a bright red blush or a fine papular eruption. 

Variations in the eruption are very frequent and very puzzling. They 
occur especially in the very mild and in the most severe cases. 

In the mild cases the rash is not seen upon the face ; it is often faint 
upon the body, and may be present only upon certain parts; when the 
rash is faint or scanty it is usually most marked in the groins and 
axillae, or over the buttocks and back of the thighs; it may last only 
one day, and sometimes may be so slight as to escape notice altogether. 
It may be absent in some very mild cases, in certain others where the 
throat symptoms are severe, and in malignant cases. In the very severe 
cases many irregularities are seen, both as to the time of the appear- 
ance of the eruption and its character. Sometimes it occurs as large, 
irregular patches; again, it is macular, closely resembling the rash of 
measles; occasionally it is of a dark purplish colour; and very rarely it 
is hemorrhagic. Xot infrequently an eruption of fine vesicles is seen, 
especially on the chest, axillae, and abdomen. It is seen both in mild 
and severe cases. This is especially diagnostic. A well-developed bright 
rash indicates strong heart action, and a sudden recession of the rash 
is a sign of heart failure. Often a rash which is faint and doubtful in 
character may be brought out fully by a hot bath. 



SCARLET FEVER. 909 

With the eruption at its height, there is intense itching or burning 
of the skin, and in severe eases considerable swelling, chiefly noticeable 
upon the hands and face. 

Desquamation. — Shortly after the rash has faded, about the eighth 
day, there begins an exfoliation of the dead epidermis, known as des- 
quamation. This is even more characteristic of the disease than is the 
rash. It is usually first seen upon the neck and chest, where it appears 
as fine flakes. The desquamation of the trunk is completed in from 
one to three weeks. If baths and inunctions are being used, it is scarcely 
perceptible. It continues longest where the epidermis is thickest — viz., 
upon the hands and feet — and here it lasts from four to seven weeks, and 
not infrequently eight weeks. The appearance of the fingers and toes 
during desquamation is characteristic. The finger tips usually peel first, 
and the new epidermis is pink and fresh-looking, while that which has 
not yet separated is of a dull gray colour and loosened at the margin. 
Occasionally the epidermis of a considerable part of a finger may be 
loosened at once, so that a partial cast may be thrown off like the finger 
of a glove. Sometimes the patient comes under observation for the first 
time during desquamation, the history of the early symptoms being 
doubtful or absent. Such desquamation as has been described, occurring 
both upon the hands and feet, may be regarded as conclusive evidence of 
scarlet fever, no matter what the history may be. In rare instances 
desquamation may include loss of the hair and the nails. 

1. The Mild Cases. — The symptoms may be so slight as to be entirely 
overlooked, nothing being noticed until desquamation occurs. Usually, 
however, there is a rather abrupt invasion, with vomiting and a tempera- 
ture from 100° to 103° F. The tonsils and pharynx are congested, while 
the palate shows a punctate redness somewhat like the cutaneous erup- 
tion. The papillae of the tip and borders of the tongue are enlarged. 
Nearly always within twenty-four hours the rash makes its appearance, 
generally first upon the neck and chest. Very often it is not seen upon 
the face, but is abundant on the rest of the body. The rash fades on 
the third or fourth day, and has disappeared by the fifth day. There is 
very little prostration, the child often being with difficulty kept in bed. 

The highest temperature is coincident with the full eruption, and 
is usually seen during the first thirty-six hours of the disease. It grad- 
ually falls to normal by the third or fourth day. Some examples are 
shown in Fig. ISO. In the mildest cases the temperature may never be 
above 100° F. 

Desquamation is often faint over the body, but is unmistakable over 
the hands and feet. It begins about the end of the first week, always 
being most marked where the eruption has been most intense. 

The mild cases are usually uncomplicated, but the possibility of otitis 
and of late nephritis should always be kept in mind, as these may occur 



910 



THE SPECIFIC INFECTIOUS DISEASES. 



even with the mildest attacks. The difficulties in diagnosis in mild 
attacks o( Bcarlel fever are often great. It should be remembered that 
these cases are just as contagious as severe ones, and that from a mild 
attack a severe one is often contracted. It is frequently by these mild 
rases that this disease is spread in schools. In dispensaries I have often 
seen patients desquamating from scarlet fever, who had been attending 



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Fig. 180. — Mild Scarlet Fever. Three cases occurring successively in the same family. 
Diagnosis not made until the third case developed, at which time the first one was found 
to be desquamating in a typical manner. 



school regularly up to the time when they were brought for treatment 
for nephritis or some other disease. 

2. Cases of Moderate Severity. — The onset is sudden with vomiting, 
which is usually repeated, rarely with convulsions. The temperature 
rises rapidly, and by the end of the first twenty-four hours has reached 
104° or 105° F. The rash generally appears within the first twenty -four 
hours, and its intensity is usually in direct proportion to the severity of 
the attack. Appearing first upon the neck or chest, it extends rapidly, 
covering the entire trunk and extremities, often in a few hours. It is 
generally typical in appearance, being made up of minute points, but giv- 
ing the appearance of a uniform blush, which has been compared to a 
boiled lobster. Little change takes place in the rash for four or five 
days. After this it fades quite rapidly, and disappears by the sixth or 
seventh day. 

The throat resembles that of the mild form, except that the redness 
is more intense and there is slight swelling of the tonsils, fauces, and 
uvula, and often pain upon swallowing. Occasionally small yellowish 
patches are seen upon the tonsils by the second or third day, but these 
can be wiped off and are not distinctly membranous. There is usually 
a moderate discharge of a sero-purulent character from the nose. The 
lymph glands at the angle of the jaw are swollen and quite tender. The 
tongue may be coated in the centre and show bright red points at its 
borders and tip, or it may be quite red and show the prominent papillae 
everywhere — the " strawberry tongue " ; while not exclusively seen in 



SCARLET FEVER. 



Oil 




Fig. 181. — Typical Temperature Curve of Uncom- 
plicated Scarlet Fever of Moderate Severity. 
Girl three years old. 



scarlatina, this is of considerable diagnostic value. It is rarely seen 
before the third day, and may continue several days or even weeks. 

During the height of the i'vxw (here is restlessness, thirst, and net 
infrequently slight delirium. The temperature usually reaches the maxi- 
mum by the second day, and falls gradually, but even in uncomplicated 
cases the fever often 
lasts from ten to four- 
teen days (Fig. 181). 
The pulse in the early 
part of the disease is 
rapid, its frequency be- 
ing usually out of pro- 
portion to the height 
of the temperature. 
There is much pros- 
tration, frequently fol- 
lowed by quite a marked 
degree of anaemia. 

This form of the disease rarely proves fatal apart from complications. 
The complications seen most frequently in this form of scarlet fever are 
adenitis, otitis, and pneumonia. Nephritis is the only common sequel. 

3. The Severe Cases. — The severe type of scarlet fever usually de- 
clares itself from the beginning. The incubation is short, and the full 
rash may be seen within a few hours after the initial symptoms. It is 
usually intense and covers the entire body, even including the face. In 
other cases the eruption is delayed, often scanty, and may disappear in 
a few hours. The disease assumes one of two fairly distinct types; one 
is characterised by the severity of the general toxaemia, the other by the 
predominance of the throat symptoms. In the first group the toxaemia 
is shown by the height of the temperature, the severity of the nervous 
symptoms, and the profound cardiac depression. The temperature 
quickly rises often to 105° or 106° F., and usually remains steadily high 
until the death of the patient. The nervous symptoms are great pros- 
tration and delirium, which is sometimes active, but more often low and 
muttering. The pulse is very rapid, 160 to 180 being not uncommon; 
it is weak, compressible, often irregular, and the muscular sounds of the 
heart are feeble. The urine is scanty and almost invariably albuminous. 
Haemorrhages from the mouth, the nose, or other mucous membranes 
are occasionally seen. The duration of the disease in this form is gen- 
erally from five to seven days. Exceptionally the symptoms develop with 
greater intensity, and death follows in three or four days. A shorter 
duration than this, the so-called malignant scarlet fever, is exceedingly 
rare. 

In the second group with predominant throat symptoms the first 



912 



THE SPECIFIC INFECTIOUS DISEASES. 



three or four days may show nothing more than cases of the moderate 
type. Membranous patches appear upon the tonsils and spread to the soft 
palate, uvula, and pharynx, Bometimes to the nose ami through the Eu- 
stachian tuhe to the ear. very rarely involving the larynx. The mucous 
membrane of the mouth is intensely congested, ami often partly covered 
by membrane; there are sordes on the lips and teeth, and there may he 
superficial ulcers, which bleed readily. The glands of the neck swell 
rapidly, often to a great size, and the cellular tissue about them is infil- 
trated. The head is thrown back to relieve the dyspnoea which the pres- 
sure from this swelling occasions. There is an abundant discharge from 
the nose and mouth ; the breath is very offensive. The general symptoms 
are those of a severe septicaemia. The temperature is steadily high, 
usually between 103° and 105° F., for about a week, after which in cases 
ending in recovery it slowly falls unless complications develop (Figs. 



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Fig. 182. — Typical Temperature Curve of Severe Scarlet Fever Ending in 
Recovery. Prolonged course due to severe throat symptoms lasting from second to 
sixth day, otherwise uncomplicated; boy twelve years old. 



182, 184, 185). But even in uncomplicated cases the fever sometimes 
continues for three weeks. In fatal cases the temperature may be stead- 
ily high till death (Fig. 183), or it may fluctuate widely. The pulse 
is rapid, weak, and irregular. There is complete anorexia; both food 
and stimulants may have to be given by gavage. There is low delirium 
or apathy, and sometimes all the symptoms of the typhoid condition are 
present. 

Signs of a broncho-pneumonia may be found in the chest, and by 
the end of the first week or early in the second, acute otitis often de- 
velops. The urine is rarely free from albumin, but the amount present 
is not usually great ; there may be hyaline and epithelial casts, and some- 
times blood. In some cases the throat symptoms predominate; in others, 
those of general sepsis, but more frequently the two are combined and 
are directly proportionate to each other. In still other cases, instead of 
the membranous inflammation, it may be of a gangrenous character, 
and extensive sloughing may take place in the pharynx or the cellu- 



SCARLET I KVER. 



913 



lar tissue of the neck, Bometimea exposing or even opening the greal 

vessels. 

Tlie duration of the symptoms in eases with severe angina is from 
seven to fourteen days. There is increasing prostration and finally a 

septic stupor, with death from exhaustion, from heart failure, or from 



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Fig. 183. — Severe Scarlet Fever, Septic Type; Death on Fourteenth Day. Intense 
angina; otitis; nephritis; necrotic inflammation of cervical lymph glands; girl seven 
years old; death from heart failure. 



some complication — broncho-pneumonia, pleurisy, nephritis, haemor- 
rhages following sloughing, pericarditis, or endocarditis. In cases which 
recover, the acute symptoms nearly always continue for a full month; 
and after escaping the dangers of sepsis and the early complications, 
the child has still to run the gauntlet of all the late complications — 
nephritis, pneumonia, endocarditis, pyaemia, etc. A case may prove fatal 
as late as the end of the seventh week; nearly all such results are due 
to nephritis or to its complications. 

4. Surgical Scarlet Fever. — The existence of a special form of scarlet 
fever occurring in patients with recent wounds or those who have been 
subjected to surgical operations, while stoutly maintained by several 
writers, has been vigorously denied by others. The question is one dif- 
ficult of solution on account of the close similarity at times existing be- 
tween the symptoms of scarlet fever and sepsis, and the necessity of 
deciding in an undoubted case whether the infection with scarlet fever 
was dependent upon or coincident with the wound. 

Hamilton, from a study of 17-4 reported cases, reached the conclusion 
that proof of the existence of a special form of scarlet fever rests upon 
the reports of cases usually meagre, and careful analysis of these would 
lead one to consider them rather as septic than as scarlatinal infections; 
that when there was undoubted evidence of scarlet fever, there was no 
proof that it was in any way due to the coincident wound, and that there 
59 



014 THE SPECIFIC INFECTIOUS DISEASES. 

is as yet no convincing proof in the literature that surgical scarlet fever 
is anything more than scarlet fever in the wounded. On the other hand, 
there have been observed clinically cases which seem to admit of no other 
reasonable explanation than that an abrasion of the skin, a recent 
wound, or even possibly a varicella vesicle, may be the point of entry 
of the scarlatinal infection, instead of the more usual portal, the pharynx. 

Relapses, Recurrences, and Second Attacks. — As a rule, one attack of 
scarlatina gives immunity through life. The exceptions are very few, 
but are well authenticated. I have seen but once an undoubted instance 
of a second attack in the same individual. 

Eelapses or recurrences within a brief period after the first attack 
are more frequent. There are to be excluded the cases of pseudo-relapses 
in which the rash, having temporarily subsided for two or three days, 
reappears; also those where the rash varies in intensity from time to 
time; and, lastly, the cases in which, occurring late in the disease, it is 
due to septicaemia or pyaemia. They are comparable to the relapses of 
typhoid fever. They occur most frequently during desquamation, be- 
tween the seventh and twenty-fourth days. There may be not only 
a new eruption, but a rise of temperature, sore throat, and vomiting, just 
as in the initial attack. These recurrences are sometimes shorter and 
milder than the first attack, but this is by no means uniform, since 
Korner mentions eight cases where the second attack proved fatal. 

In considering the subject of second attacks, the liability to errors in 
diagnosis must be borne in mind and only cases included which have pre- 
sented typical symptoms. 

Special Symptoms, Complications, and Sequelae. — Temperature. — 
The temperature curve of this disease is quite characteristic. There 
is usually seen an abrupt rise, the maximum being reached on the sec- 
ond day; there follows a period of variable duration, generally lasting, 
according to the severity of the case, from two to five days, in which the 
fluctuations are very narrow; then a gradual decline to normal, which 
is reached in the milder cases in about a week; in those which are more 
severe, in about two weeks. This typical curve (Figs. 179 and 180) is 
seen in the great proportion of uncomplicated cases which end in recov- 
ery. Deviations from it, therefore, are important as indicating that 
some complication exists. The explanation is usually to be found in the 
development of otitis, adenitis, nephritis, pneumonia, etc. Severe throat 
symptoms prolong the temperature but do not usually modify its course. 
In very severe cases ending fatally the high temperature is prolonged. 
In any case, a rise after the third day is unfavourable. 

Throat. — Three distinct forms of angina are seen in scarlatina : sim- 
ple or erythematous, membranous, and gangrenous. 

1. Erythematous Angina. — This can hardly be ranked as a com- 
plication, as it is nearly as constant as the scarlatinal rash. Usually 



SCARLET FEVER. 915 

there is only the intense genera] blush over the entire pharynx with 
the fine red points upon the hard palate; hut there may lie seeD upon 
the tonsils grayish-yellow spots resembling those of follicular tonsil- 
litis, which can be wiped off, leaving a clean surface. This simple 
angina is at its height with the maximum temperature, and fades 
the temperature falls. It does not often extend to adjacent mm 
membranes. 

2. Membranous Angina. — These cases were formerly classed as scar- 
latinal diphtheria, and whether this process was identical with primary 
diphtheria or not, was for a long time a subject of much discussion. 
Cultures have shown that the great majority of these inflammations are 
not true diphtheria, but are due to the streptococcus. 

The lesions of this form of angina are considered in the chapter on 
Membranous Tonsillitis. Usually on the second or third day of the dis- 
ease an exudation appears upon the tonsils, and in the milder cases it 
covers only the tonsils. In the most severe form it may be seen within 
twenty-four hours of the onset, sometimes before the eruption appears. 
Beginning upon the tonsils, the membrane rapidly spreads to the entire 
pharynx, the mucous membrane of the nose, the mouth, the Eustachian 
tube, and even to the middle ear. In colour it may be gray, greenish, or 
almost black. There is so much swelling of the throat that swallowing 
becomes difficult. The infiltration of the cellular tissue of the neck and 
the enlarged lymph glands produce great external swelling, which may 
extend like a collar from ear to ear. The breath has a foul odour, the 
nasal discharge is thin and foetid, and nasal respiration is obstructed, so 
that the mouth is open constantly. It is surprising that the larynx is so 
seldom invaded. 

These local changes are accompanied by constitutional symptoms of 
great severity, which are due to a general streptococcus septicaemia ; 
broncho-pneumonia and nephritis are very frequent, otitis is almost con- 
stant, and suppuration of the lymphatic glands is not uncommon. The 
eruption is often irregular and late in appearing. 

The frequency with which diphtheria coexists with scarlatina varies 
greatly. In hospital practice the proportion often runs as high as thirty 
or forty per cent. In private practice it is much lower. In some epi- 
demics it is much more frequent than in others. The streptococcus an- 
gina is usually seen at the height of the disease; true diphtheria may 
occur at any time, even during convalescence. Very little reliance is to 
be placed upon the appearance of the membrane. The only positive 
means of differentiation is by cultures, which should invariably be made 
from the throat of every patient admitted to a scarlet-fever hospital, and 
of every case in private practice showing any exudate upon the tonsils. 
If the first culture is negative and the throat symptoms increase, re- 
peated cultures should be made. 



916 THE SPECIFIC INFECTIOUS DISEASES. 

3. Gangrenous Angina. — This is Been only in the worst cases of scar- 
let fever. The process may be gangrenous Erom the outset, or preceded 
by a membranous inflammation. It is sometimes insidious in its de- 
velopment. There is a foetid odour to the breath, an irritating discharge 
from the nose and mouth, with very great glandular swelling. The ton- 
sils are gray or grayish-black in colour, and large masses of necrotic 
tissue may be removed with the forceps from the tonsils, uvula, fauces, 
or pharynx, and sometimes sloughing occurs in the cellular tissue of the 
neck. Blood-vessels of considerable size are sometimes opened, and 
serious or even fatal haemorrhage may result. The constitutional symp- 
toms are those of great asthenia, prostration, and profound cachexia, 
followed almost invariably by a fatal termination. 

Lymph Xodes. — These are swollen in all cases accompanied by severe 
angina. The inflammation may be simply an acute hyperplasia, or it 
may go on to suppuration and necrosis. Abscess does not often occur 
at the height of the disease, but the early swelling may almost completely 
subside only to recur, and suppuration may take place even as late 
as the fifth or sixth week of the disease. It may be confined to the 
glands or be complicated by suppuration in the cellular tissue of the 
neck. 

Cellulitis of the Neck. — This usually occurs toward the end of the 
first week, and is associated with grave throat symptoms. Eapid and 
extensive infiltration occurs, the skin becomes tense and brawny, the 
head is held back, and there may be considerable dyspnoea. The infil- 
tration may be only in the neighbourhood of the lymph glands or it 
may be diffuse. Unless relieved by early incision, the diffuse form may 
result in suppuration and extensive sloughing, which may be deep 
enough to lay bare the large vessels of the neck. This is a complication 
of the gravest possible import. Death may occur from septicaemia be- 
fore or after sloughing or from haemorrhage due to opening by ulcera- 
tion of the external carotid or some of its branches; or there may be 
associated thrombosis of t!:e jugular vein, leading to thrombosis of the 
lateral sinus, meningitis, or pyaemia. 

Ears. — The otitis is due to direct extension of the infection from 
the rhino-pharynx. It is the most frequent complication of scarlatina, 
and in doubtful cases may have some diagnostic importance. As a rule, 
the younger the child the greater the liability to otitis. It is more fre- 
quent in winter than at other seasons, and is closely connected with the 
severity of the throat symptoms. In an epidemic occurring in the Xew 
York Infant Asylum in spring and summer there were 73 cases of scar- 
latina and not one of otitis. In a fall and winter epidemic in the same 
institution two years later, of 43 cases 20 per cent had otitis. Of 4,397 
cases reported by Finlayson, otitis occurred in 10 per cent, and of 1,008 
cases reported by Caiger, in 13 per cent. In Burkhardt's statistics the 



SCARLET FEVER. 



917 



proportion was as higli as 33 per cent. Of cases accompanied by severe 
throat symptoms otitis is present in fully 75 per cent. 

As a rule, both ears are affected. Otitis is most frequent early in the 
second week, but may occur at any time, even during convalescence. In 
the cases when it develops at the height of the disease; (here are in some 
cases no new symptoms; in others there is pain and deafness and a rise 
in the temperature, which may fall after paracentesis or rupture of the 
drum membrane, or there may be extension to the mastoid (Fig. 184). 



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Fig. 184. — Severe Scarlet Fever; Otitis; Mastoiditis; Death. Typical symptoms 
and temperature curve until fourteenth day; secondary rise of temperature from 
otitis; double paracentesis on the fifteenth day; mastoid operation on the sixteenth 
day; death twelve hours later from septicaemia; boy five years old. 



The otitis is often overlooked unless the ears are regularly examined. 
The 'form of inflammation may be catarrhal or purulent, the latter being 
often accompanied by necrotic changes. 

Bezold makes the following report upon 185 cases showing the dis- 
astrous consequences of scarlatinal otitis : "In 30 there was entire 
destruction of the membrana tympani; in 59 the perforation comprised 
two-thirds or more of the membrane; in 15 there was total loss of hear- 
ing on one side, and in 6 of the cases upon both sides ; in 77 of the cases 
the hearing distance for low voice was less than twenty inches." 

As a cause of permanent deafness and deaf-mutism, no disease of 
childhood compares in importance with scarlet fever. May has collected 
statistics of 5,613 deaf-mutes, of whom 532 owed their condition to 
otitis following scarlet fever. 

Kidneys. — Albuminuria accompanies nearly all the severe cases of 
scarlet fever. In many this is simply the ordinary febrile albuminuria 
due to acute degeneration of the kidneys. In those with severe throat 
complications, and in nearly all the septic cases, there is an acute diffuse 
nephritis; the interstitial changes may be very marked and the kidneys 
contain minute abscesses. This occurs at the height of the febrile process 



918 



THE SPECIFIC INFECTIOUS DISEASES. 



and is rarely accompanied by dropsy; but albumin, casts, and even blood 
may be found in the urine. The most severe and the most characteristic 
renal complication, and that generally designated as post-scarlatinal 
nephritis, is a diffuse nephritis, with changes in the glomeruli as the 




Fig. 185. — Scarlet Fever of Moderate Severity Followed by Fatal Nephritis. 
Early symptoms typical and uncomplicated; twenty-first day vomiting; twenty-fifth 
day uremic convulsions; death twenty-sixth day. No dropsy; urine never below 
10 ounces in twenty-four hours; girl ten years old. 



most striking feature. It usually develops during the third or fourth 
week of the disease, and may follow mild as well as severe cases (Fig. 
185). The onset may be gradual, with dropsy and urinary changes, 
usually accompanied by a slight rise of temperature ; or it may be abrupt, 
without dropsy but with convulsions, suppression of urine, and very 
high temperature. 

The characteristic urine is of a reddish or smoky colour and scanty. 
It contains a large amount of albumen, often sufficient to render the 
urine solid upon boiling. Under the microscope there are seen red 
blood cells, pus cells, epithelial cells, and casts of every variety. Death 
may take place ironi acute uraemia, or the attack may be followed by 
permanent damage to the kidneys. It is more fully described with the 
Diseases of the Kidney. 

Joints. — Acute articular rheumatism may occur coincidently with the 
development of the scarlatinal rash, and occasionally during convales- 
cence in patients who have a predisposition to that disease. Acute swell- 
ing of the joints is sometimes of pysemic origin. In pysemic arthritis the 
large joints are usually involved and the lesions are apt to be multiple. 
Joint disease may occur as a sequel of scarlet fever, when it is sec- 
ondary to disease of the bone or to periarticular abscesses opening into 
the joint. 

The foregoing include but a small proportion of the joint complica- 
tions seen in scarlet fever. The most frequent and most characteristic 
form of inflammation is scarlatinal synovitis, often improperly called 
scarlatinal rheumatism. It occurs in different epidemics with varying 
frequency. Carslaw (Glasgow), in 533 cases of scarlet fever, met with 
synovitis in 60 patients. It is seldom seen in children under three years 



SCARLET FEVER. 919 

of age, and is most frequent after five years. It may occur in mild as 
well as in severe cases. According to Ashby, synovitis develops toward 
the end of the first or the beginning of the second week. The symptoms 
are generally mild, and are followed by prompt recovery. Suppuration 
is rare. Any of the joints may be attacked, but those of the wrist, hand, 
elbow, or knee are most frequently affected. The symptoms are redness, 
moderate pain, swelling, which is usually due to synovial distention, and 
sometimes a slight rise in temperature. The duration is generally but 
three or four days, and in most cases there is spontaneous recovery. Be- 
sides these milder cases there occurs a much more severe form, which 
may develop later, even during convalescence. It is not very acute, but 
is accompanied by fever, and both the fever and swelling may continue for 
many weeks. Recovery may be complete or some joint disability may 
remain and chronic arthritis may follow. 

Lungs. — The pulmonary complications of scarlet fever are neither 
so frequent nor so important as those of measles. Broncho-pneumonia 
is usually found at autopsy in septic cases where death has occurred later 
than the third or fourth day, but it is not generally recognisable so early 
by physical signs. 

In septic cases pleuro-pneumonia sometimes occurs early in the dis- 
ease and at other times late, generally associated with nephritis, but 
occasionally without it. It is always a serious condition, and not in- 
frequently a direct cause of death. Empyema may follow pleuro-pneu- 
monia or occur with pyaemia or nephritis, but with the latter, simple 
serous pleurisy is more common. (Edema of the lungs occurs chiefly 
with nephritis, in which it is the most common cause of death. 

Heart. — Cardiac murmurs are frequent at the height of the disease; 
in fact they are heard in almost all severe cases. Endocarditis and peri- 
carditis are oftenest seen in septic cases, and with post-scarlatinal neph- 
ritis. Endocarditis may be simple or malignant, and may lead to em- 
bolism during convalescence. Some degenerative changes in the cardiac 
muscle are probably present in all the severe cases. Acute dilatation may 
result, which is sometimes a cause of death. 

Blood. — In all cases there is a rapidly progressing anaemia that lasts 
into convalescence. The reduction in the red cells in an average case is 
about one million. The chief interest, however, attaches to the number 
and character of the white cells. In mild cases there may be only a 
moderate increase in their number, usually to from 10,000 to 14,000. 
It is in cases of moderate severity that the characteristic changes are 
found. In these there is a decided leucocytosis which appears early, 
attains its maximum about the fourth day, and gradually declines until 
the normal is reached, which may not be until the third, fourth, or fifth 
week. The maximum is usually about 30,000 to 35,000; although it may 
be as high as 75,000. During the first week the polymorphonuclear 



920 THE SPECIFIC INFECTIOUS DISEASES. 

neutrophils form from 90 to 95 per cent of these cells; the eosinophiles 
as well as the lymphocytes are diminished. After the fifth or sixth day, 
there is a rapid increase in the eosinophiles which attain their maximum, 
sometimes 80 per cenl of the total leucocytes, between the fourteenth 
and twenty-firsl days. After the third week they gradually diminish. 
Exceptionally there is found in convalescence a relative lymphocytosis, 
which may be as high as 50 per cent. Complications, nephritis excepted, 
usually show actual as well as relative increase in the polymorphonuclear 
neutrophiles. \\\ malignant and rapidly fatal cases there is usually a 
verv small proportion of eosinophiles, and little if any leucocytosis, though 
exceptionally it may be high. 

Digestive System. — Functional disturbances are very frequent, and, in 
fact, are seen in most of the cases, but organic changes are rare. Vomit- 
ing is the mode of onset in the majority of cases, but rarely continues 
throughout the attack. Late in the disease it is a frequent symptom of 
uraemia. Diarrhoea may be associated with it under both conditions. 
The tongue is nearly always coated, and clears off in quite a characteristic 
way, which, with the prominent papillae, gives rise to the " strawberry " 
appearance. Catarrhal stomatitis is a very frequent complication, and 
in many cases of severe membranous angina the same process is seen in 
the buccal cavity. 

Nervous System. — Nervous complications and sequelae are seen less 
frequently with scarlatina than with most of the infectious diseases of 
such severity. Convulsions are frequent at the outset, and generally 
indicate a severe attack, though not invariably so. Occurring late in 
the disease, they are usually due to uraemia, and may be a cause of death. 
Meningitis may occur as a complication of otitis, in pyaemic cases, and 
sometimes with post-scarlatinal nephritis. Paralysis from peripheral 
neuritis is rarely seen. Hemiplegia sometimes occurs from meningeal 
haemorrhage, or from embolism secondary to endocarditis and associated 
with nephritis. Chorea was noted as a sequel in only three of 533 cases 
reported by Carslaw. In a report of 187 cases of epilepsy, Wildermuth 
states that it followed scarlet fever in 12 cases. Insanity has been occa- 
sionally observed, the usual form being acute mania, with complete 
recovery in a few weeks or months. 

Gangrene. — Cases of symmetrical gangrene after scarlet fever have 
been reported. The parts generally affected are the buttocks, thighs, 
and arms, but it may occur almost anywhere. The pathology of these 
cases is ohscure. The process usually begins in several places simul- 
taneously, or in rapid succession, and advances steadily till death 
occurs. 

Other Infectious Diseases. — Diphtheria is most frequently seen, and 
may be present even when there is no distinct membrane. 

Scarlatina may also be complicated by measles, varicella, or facial 



SCARLET FEVER. 921 

erysipelas, and occasionally by variola or typhoid fever. The symptoms 
are often an irregular commingling of those belonging to the two dis- 
eases. They may begin simultaneously, or more frequently one develops 
as the other is subsiding. 

Diagnosis. — The characteristic symptoms of scarlet fever are the 
abrupt onset, usually with vomiting, the marked elevation of tempera- 
ture, the erythematous condition of the throat, the punctate eruption on 
the hard palate, with the appearance of the rash within twenty-four 
hours, and later the characteristic appearance of the tongue. The diffi- 
culties of diagnosis usually depend upon irregularities in the eruption. 
The variations are seen in the mildest and in the most severe cases. 
In the former the rash may be of short duration, often less than a day, 
and in consequence easily overlooked; or it may be present only upon 
certain parts of the body instead of being diffuse. In every doubtful 
case the groins, axillae, and loins should be closely scrutinised for a punc- 
tate eruption. In very severe attacks also the rash may be uncertain. 
It may appear late or recede after being fully out, or it may be hemor- 
rhagic or in irregular blotches instead of a uniform blush. In all case-, 
too much stress should not be placed upon the rash alone. 

Until we have some exact means of laboratory diagnosis as in typhoid 
fever, malaria, and diphtheria, an absolute diagnosis will in certain cases 
be impossible. Sometimes the diagnosis remains doubtful until the end, 
although occasionally confirmatory evidence may be obtained even in 
convalescence. Thus, a patient may desquamate in a manner so typical 
as to leave no doubt as to the nature of the preceding illness; again, 
the occurrence of a characteristic sequel, such as nephritis in the third 
or fourth week, may testify strongly for scarlatina as the primary disease ; 
and, finally, the outbreak of undoubted cases among children who have 
been in contact with the patient is practically conclusive, always pro- 
vided other sources of infection can be excluded. Desquamation, how- 
ever, follows so many other eruptions that when slight or irregular one 
should not rely upon it as an evidence of scarlet fever, but only upon 
a typical exfoliation upon the hands and feet. It is a point of some 
practical importance not to oil the skin of a patient when awaiting 
desquamation for diagnosis, as this alters very much the characteristic 
appearances. In some puzzling epidemics the length of the incubation 
may be of material assistance in the diagnosis; where this is regularly 
more than a week, one may be pretty sure that he is not dealing with 
scarlet fever. 

Scarlet fever with severe throat symptoms and doubtful eruption 
can be distinguished from diphtheria only by cultures, which should 
be made early and repeated if the first result is uncertain. Measles is 
distinguished from scarlet fever by the length of the invasion, the 
catarrhal symptoms, and the slowly spreading eruption, but most of 



\^2 THE SPECIFIC INFECTIOUS DISEASES. 

all by Koplik's spots. Much more difficult is it to distinguish betweon 
mild scarlatina and rubella. In rubella the important thing is that, 
although the rash may be well marked, often covering the body, the 
constitutional symptoms are few or entirely absent. In scarlet fever 
with an eruption of the same intensity there is almost invariably a 
considerable elevation of temperature, usually 102° or 103° F., and a 
bright red throat. 

There are bo many skin eruptions which may resemble that of scarlet 
fever, that it is always hazardous to make the diagnosis of this disease 
from the eruption alone. This is especially true of sporadic cases occur- 
ring in infants; there is seen at this age a great variety of eruptions, 
usually associated with digestive disturbances, which closely simulate a 
scarlatinal rash; but most of them are of short duration. A scarlatini- 
form erythema is occasionally seen after diphtheria antitoxine, also in 
influenza, typhoid fever, pneumonia, and varicella, which may cause 
them to be mistaken for scarlet fever, or may lead to the conclusion that 
both diseases are present. The same is the case with the septic erythema 
occurring in surgical patients. Belladonna, quinine, and occasionally 
antipyrine, the salicylates and aspirin may produce eruptions more or 
less closely resembling that of scarlet fever. This is also true of some 
cases of urticaria and other forms of skin disease. Eruptions resembling 
scarlet fever may also arise from irritation due to clothing, to heat, to the 
local application of irritants to the chest, such as camphorated oil, etc. 
There is little doubt that many of the cases reported as relapsing scar- 
latina are really examples of recurring erythema, particularly as some 
of the latter are followed by a desquamation which is very similar to 
that after scarlatina. In all doubtful conditions great importance is 
to be attached to the constitutional symptoms. 

Prognosis. — There is no disease in which it is more difficult to foretell 
the outcome than in scarlet fever. Cases apparently of the mildest type 
not infrequently develop serious symptoms and even complications that 
could not be foreseen. Symptoms indicating a bad prognosis are, very 
high temperature, especially one which continues to rise for the first three 
or four days, and severe nervous and throat symptoms. The most com- 
mon cause of death is the disease itself, the scarlatinal toxaemia. From 
this cause more than half the deaths occur. Next are the complications, 
cardiac, pulmonary, renal, otitic, mastoid and cerebral, given in the order 
of their frequency. The mortality of scarlet fever varies much in dif- 
ferent epidemics. In some, nearly all the cases are of a mild type, and 
the mortality may be as low as 3 or 4 per cent; in others, a severe or 
malignant type prevails, and it may be as high as 40 per cent. The 
3e is, as a rule, more fatal in the youngest infants, becoming less 
age advances. This is well shown in two epidemics in the New 
York Infant Asylum. There were — 



SCARLET FEVER. 923 

Under one year 29 cases; mortality, 55 per cent. 

From one to two years 37 " " 22 " " 

From two to three years 28 " " 7 " " 

Over three years 23 " " " " 

In the first epidemic the general mortality was 12.5 per cent; in 
the second it was 33 per cent in the same class of children. 

The following are the mortality records from various European 
sources : 

Ashby, Manchester Hospital 681 cases; mortality, 12.2 per cent. 

Koren, a single epidemic 426 " " 14.0 " " 

Bendz, Copenhagen 22,036 " " 12.2 " " 

Ollivier, three Paris hospitals for five years . . 893 " " 14.0 " " 

Fleischmann, five epidemics 1,356 " " 10.0 " " 

The general mortality of the disease may therefore be assumed to be 
from 12 to 14 per cent; it is, however, much higher than this among 
young children, as shown by the following figures: 

New York Infant Asylum 116 cases under 5 years; mortality, 20 per cent. 

Ashby, Manchester Hospital 259 " " 5 " " 23 " " 

Bendz not stated (( 5 " " 13 " " 

Heubner 136 cases " 7 " " 30 " " 

Fleischmann not stated " 4 " " 43 " " 

Under five years of age the average mortality from scarlet fever is, 
therefore, between 20 and 30 per cent. 

Prophylaxis. — Even the mildest cases should be isolated for four 
weeks, and all cases until desquamation is complete. If complications 
exist, such as otitis, rhinitis, pharyngitis, empyema, or suppurating 
glands, the quarantine should be continued until these conditions are 
cured. Patients should not be allowed to mingle with other children for 
at least a month after all symptoms have subsided, and should be for- 
bidden to sleep with other children for three months. Children in the 
house who have not been exposed to the disease should be immediately 
sent away ; and those who have been exposed, separately quarantined for 
at least a week. After recovery, the patient, before mingling with other 
children, should have at least two disinfectant baths, the entire body 
being scrubbed with soap and water and then washed in a solution of 
carbolic acid (1 to 50) or bichloride (1 to 5,000), and every particle of 
clothing changed. The hair and the scalp should be thoroughly washed 
and disinfected. 

The nurse should be quarantined with the patient, and should not 
mingle with other members of the family until a complete change of 
clothing has been made, and hands and face and hair thoroughly disin- 
fected. The nurse and all others in close contact with a severe case 
should use frequently an antiseptic gargle and a nasal spray. The room 



024 THE SPECIFIC INFECTIOUS DISEASES. 

should be in thai part of the house most easily quarantined, usually on 
the top floor; during the attack it should be stripped of upholstery, 
hangings, and carpet, and should be freely ventilated and kepi as clean 
a> possible. All dust should be removed with damp cloths which should 
afterward be burned; the floor should occasionally be sprinkled with a 
bichloride solution (1 to 1.000). The presence in the room of vessels 
filled with antiseptic fluids is of no practical value. The same may be 
said of sheets wet in carbolic or other solutions and hung about the 
room. Carbolic-acid poisoning has been known to result from this 
practice. Alter an attack it should be remembered that the room is 
probably a greater source of danger than the patient. Smooth walls 
should be wiped with damp cloths wrung out of a bichloride solution 
(1 to 2,000). The wood-work should be washed in the same solution 
and the floor scrubbed with it. After a thorough cleaning, while the 
floor is still wet and walls damp, the apartment should be fumigated 
with sulphur, or better with formaldehyde. Of the various methods of 
generating formaldehyde, that of Wilson 1 is probably the cheapest, sim- 
plest, and most effective. If fumigation is to be efficient the room must 
be tightly closed, all cracks being stopped with cotton, and larger open- 
ings about doors, windows, and fireplaces sealed by pasting paper over 
them. Bedding, cushions, pillows, carpets, etc., should be hung over 
chairs or upon lines strung about the room. Books should be sus- 
pended from covers so that the leaves are exposed. After fumigation, 
the room should remain closed for twelve hours. After a severe case, the 
walls should be painted or whitewashed, or if papered, the wall-paper 
should invariably be renewed and the wood-work repainted. Simply 
airing a room after an attack is of little or no benefit. An instance is 
on record of a patient contracting the disease in a room in which the 
windows had been open constantly for three months. The carpets, 
bedding, hangings, and upholstery can be disinfected only by steam 
under pressure. Where this is impossible, after a severe case the mat- 
tress and pillows should be burned. Bedding, blankets, and other articles 
should be boiled. 

The bedclothes, linen, and clothing removed from the patient during 
an attack, should be put at once into a solution of carbolic acid (1 to 
20), or zinc sulphate four ounces, common salt tw T o ounces, and water 
one gallon, and afterward boiled in the same solution. Instead of 

1 For each 1,000 cu. ft. of space there is required 1 lb. of absolutely quick lime, 
6 oz. of a 40-per-cent solution of formaldehyde, 2 oz. of a saturated solution of alumi- 
num sulphate. The ingredients may be mixed in a bucket or bowl, which should 
stand upon wood or in a vessel containing water, as considerable heat is generated. 
The lime is first moistened with water; then the two solutions previously mixed are 
poured on and thoroughly mixed with the lime by stirring. The liberation of the 
formaldehyde gas takes place very rapidly, practically all of it in fifteen or twenty 
minutes. For a large room several receptacles are better than a single large one. 



SCARLET FEVER. 926 

handkerchiefs, pieces of old muslin, Burgeon's gauze, or absorbenl cot- 
ton should be used for cleansing the nose; and mouth of the patient 
and burned immediately. 

The physician in attendance should leave his coat and overcoat in 
an anteroom, and put on a cap and a long gown or rubber coat, suffi- 
ciently large to cover all his clothing. Rubber gloves may be worn as 
an additional precaution. The gown and cap should always be worn in 
the sick-room, and boiled or disinfected when the case is finished. For a 
single visit the overcoat may he worn in the room, but the clothing 
should he changed before visits to other children are made. After every 
visit the physician's hands and face should be thoroughly washed with 
soap and then with a disinfectant solution. A physician in attendance 
upon scarlatinal patients should not attend obstetric cases or Other 
patients with recent wounds. 

Schools are hot-beds for the spread of scarlet fever. The greatesl 
sources of danger are the mild or walking cases in which the disease has 
not been recognised, and the clothing of patients who have had a severe 
form of the disease. As a rule, a child should be kept from school six 
weeks from the beginning of the attack, and the certificate of a physician 
should be required before readmission, stating not only that the des- 
quamation is complete, but also that the child is suffering from no 
sequelae. Other children in the household should not be allowed to attend 
schools of any kind during the period of active symptoms; they should 
be kept at home on the average for a month. This precaution is neces- 
sary, first, because they might carry the disease from the patient at home ; 
secondly, because otherwise they might themselves attend school while 
suffering from the disease in a very mild form or during the period of 
invasion. When the sick child is completely isolated, the danger from 
the first source is very slight. During severe epidemics it frequently 
becomes necessary to close all schools. 

During desquamation the spread of the disease may be in a measure 
prevented by the free use of inunctions and warm antiseptic baths. All 
the excreta from the patient should be disinfected throughout the dis- 
ease, best by a carbolic solution (1 to 20). If cases of scarlet fever are 
to be transported, this should be done only in a vehicle which can be 
easily disinfected. Under all circumstances as few persons as possible 
should come in contact with the patient. 

In general, it is to be remembered that the danger is first from the 
patient, secondly from the room, and thirdly from the nurse. Special 
attention should always be given to the complete and immediate isolation 
of the first case which appears in an institution or community, which 
should apply to mild as well as severe forms of the disease. 

Treatment. — There is as yet no specific for scarlet fever. The physi- 
cian's duty in the average case consists in (1) establishing proper quar- 



926 THE SPECIFIC INFECTIOUS DISEASES. 

antine and the carrying out of adequate means of disinfection; (2) the 
hygienic care of the patient; (o) directing the diet; (4) watching for 
complications, especially otitis and nephritis. It should be borne in mind 
that otitis is rarely accompanied by pain or tenderness, and is recognised 
only by an examination of the ears; also that severe and fatal nephritis 
may follow mild as well as severe cases. 

Mild attacks require no medicine. Children should be kept in bed 
for at least a week after the fever has subsided, and upon a diet of milk 
and farinaceous food with plenty of water for a period of three weeks. 
This is an important matter in the prevention of nephritis. During 
the height of the eruption, the intense itching of the skin may be allayed 
by sponging with a bicarbonate of soda solution, or by inunctions with 
vaseline, or by the free use of rice or talcum powder. Plenty of fresh 
air should always be secured in the sick-room. As soon as the fever 
and rash have disappeared, daily warm baths with soap and water should 
be used, after which the entire body should be anointed with vaseline, 
with the purpose of facilitating desquamation. In case the skin becomes 
irritated by this treatment, bran baths may be substituted for soap 
and water. 

The temperature does not usually require interference when it only 
occasionally rises to 104° or 104.5° F. But if there is hyperpyrexia, or 
a temperature which ranges from 104° to 105.5° F. or over, antipyretic 
measures are called for. Hydrotherapy is much safer and more certain 
than drugs. Sometimes sponging is sufficient, but in the great propor- 
tion of cases the pack or bath is required. The use of water in the 
reduction of temperature is especially indicated in septic cases with 
typhoid symptoms, and in those with pronounced cerebral symptoms. 
The temperature of the water employed will depend upon the duration 
of its application. It is generally better to use prolonged sponging or 
bathing with tepid water than water at a lower temperature for a shorter 
period. 

The nervous symptoms are frequently better controlled by ice to the 
head and by cold sponging than by medication. Antipyretic drugs may 
be relied upon to control restlessness and promote sleep, and in mild 
cases to effect a moderate reduction in temperature. Phenacetine is 
usually to be preferred. 

As soon as the pulse becomes weak or rapid and irregular, or the 
first sound of the heart feeble, stimulants should be given, no matter at 
what stage of the disease. In septic, or malignant cases, or in those 
accompanied by severe angina, adenitis, or cellulitis, stimulants should 
be used freely. Digitalis is especially valuable when the pulse is weak 
and the tension low. It may be given alone or combined with caffein; 
one minim of the fluid extract of digitalis, and gr. £ of caffein being 
the initial doses for a child of five years. 



MEASLES. 927 

The erythematous sore throat requires no treatment except the use 
of a bland gargle. If there is a profuse nasal discharge, gentle nasal 
syringing with a warm saline or boric-acid solution may be used with 
the hope of preventing infection of the middle ear. The local treat- 
ment of the throat is the same as that of other cases of severe angina. 

Milder forms of adenitis require no local treatment. When severe, 
the glands should be covered with ichthyol, and an ice-bag applied con- 
tinuously. Poulticing almost invariably does harm. If an abscess forms, 
early incision should be practised. 

The ears of patients with severe throat symptoms should be examined 
daily in order that there may be no delay in performing paracentesis 
should this become necessary. Any rise in temperature should direct 
attention to the ears. The indications for the operation are the same 
as in other severe forms of otitis. 

The physician should be constantly on the watch for the development 
of nephritis, not only during the febrile period, but also during con- 
valescence. Eepeated examinations of the urine are absolutely necessary. 
These are much facilitated by having a rack of test tubes and the ordi- 
nary reagents for detecting albumin in the sick-room, so that the physi- 
cian may himself examine daily a fresh specimen of urine. The nurse 
should be instructed to measure and record accurately the twenty-four 
hours' urine throughout the attack. The treatment of scarlatinal 
nephritis has been considered in the chapter devoted to Diseases of the 
Kidney. Diffuse cellulitis of the neck calls for free, early incision as the 
only means of preventing extensive sloughing. 

Sera prepared by means of several different varieties of streptococci 
have been produced and extensively used without any uniform or striking 
success. One has been produced by Moser (Vienna), concerning whose 
effects there is much more favourable evidence. Escherich, Bokay, and 
other reliable Continental observers in their reports have declared that 
its effects are not less striking than those obtained from diphtheria 
antitoxine. It is not yet available in this country. 

During convalescence, the urine should be frequently examined; 
antiseptic gargles and a nasal spray should be used as long as a purulent 
discharge from the nose or pharynx continues. 



CHAPTEE II. 

MEASLES. 

(Rubeola, Morbilli.) 

Measles is an epidemic contagious disease, more widely prevalent 
than any other eruptive fever ; very few persons reach adult life without 



928 THE SPECIFIC ENFECTiOUS DISEASES. 

contracting it. One attack usually confers immunity. It is highly con- 
tagious even from the beginning of the invasion, and spreads with great 
rapidity from the patient to all susceptible persons exposed. The infec- 
tious agent, however, does not cling so long to clothing or apartments 
as does that o( scarlet fever. Measles has a period of incubation of 
from eleven to fourteen days; a gradual invasion of three or four days 
with symptoms o( an acute coryza, and a maculo-papular eruption which 
appears tirst upon the face and spreads slowly over the body, and which 
lasts from four to six days. This is followed by a fine bran-like des- 
quamation, which is complete in about a week. The mortality is low, 
except among infants and delicate children, in whom it may reach 30 
or even 40 per cent. In institutions for infants and young children 
no disease is more to be dreaded than measles, not only on account of 
its severity, but from the frequency with which, in such subjects, it is 
complicated by broncho-pneumonia. 

Etiology. — The essential cause of measles is as yet unknown. It is 
generally believed to be due to a micro-organism, but, as in the case of 
scarlatina, all attempts to isolate it have thus far been unsuccessful. 
The virus is one which possesses remarkable powers of diffusion, but 
whose viability is much less than that of most of the pathogenic germs 
which are known. Only a short exposure is required to communicate 
the disease, and even close proximity to a patient does not seem neces- 
sary. One instance has come under my own observation wdiere measles 
was apparently eonvev^ed by an exposure of half an hour across a hos- 
pital w T ard, a distance of at least fifteen feet. 

Predisposition. — Very young infants do not so readily contract 
measles, but all other children are extremely susceptible. The disease 
broke out in a cottage of the Xew York Infant Asylum wdrich was occu- 
pied by twenty-three children, nearly all of them being under two years 
old; only four escaped, all these being under five months old. In an 
epidemic reported by Smith and Dabney, 110 unprotected children, 
between the ages of eight and eighteen years, were exposed and only 
two escaped. In the Xursery and Child's Hospital, during an epidemic, 
there w r ere 62 children over two years of age; five were protected by a 
previous attack and escaped; of the remaining 57 children, 55 took the 
disease. There w r ere also in the institution 113 children under two years 
old ; of this number 78 per cent took the disease ; but, although a num- 
ber were exposed, not one child under six months old contracted measles. 
The age of the persons affected depends much upon the length of time 
since the last outbreak of the disease. In an epidemic occurring in the 
Island of Guernsey, where the disease had not prevailed for many years, 
all ages were affected, the youngest being twelve days old, and the oldest, 
a man and wife, each aged eighty years. Somer has reported an instance 
of an eruption of measles appearing in a child twelve hours after birth; 



MEASLES. 929 

the mother was suffering from the disease at the time. Gautier has 
collected blx additional cases, where measles either existed at the time 
of birth or developed within a few hours after it. 

Except, then, in early infancy, the probabilities are very strong that 

every child exposed to measles will contract the disease. Occasionally, 
however, one is seen who seems insusceptible to the poison, no matter 
how close the exposure. 

Epidemics of measles are more frequent and more severe during the 
winter and spring months. They are least frequent and mildest during 
the autumn months. 

Incubation. — In 1-U cases, 1 in which the period of incubation could 
be definitely traced, it was as follows : 

Incubation of less than nine days 3 cases. 

" " nine or ten days 22 " 

' eleven to fourteen days 95 " 

u " fifteen to seventeen days 19 " 

4>; eighteen to twenty- two days 5 " 

Thus in 66 per cent of the cases the incubation was between eleven and 
fourteen days, and in only one case was it less than a week. The con- 
stancy of the incubation period is strikingly shown in some epidemics. 
Thus in the one reported by Smith and Dabney in an institution in 
Virginia, exactly eleven days after the rash appeared in the first case, 
the disease developed in twenty children — no cases having occurred in 
the interval. 

Duration of the Infective Period. — This is much shorter than in 
scarlet fever, and the average duration may be placed at three weeks. 
Haig-Brown discharged fifty-eight cases on or before the twenty-ninth 
day of the disease, and in no instance was measles spread by these 
children. Eansom, however, records one instance in which it was com- 
municated thirty-one days after the appearance of the rash. 

Measles is highly contagious from the beginning of the catarrhal 
symptoms. A case occurred in the Babies' Hospital under my own ob- 
servation, in which a child conveyed the disease four days before the rash 
appeared. Eansom reports another precisely similar. An instance has 
been related to me by Dr. S. W. Lambert, where, of thirteen little girls 
who were at a children's party, only one escaped measles, the source of 
infection being a child who showed no rash until the following day ; the 
child who escaped had previously had measles. The period of greatest 
contagion is still a matter of dispute, the general belief being that it is 
coincident with the highest temperature, the full eruption, and the most 
severe catarrhal symptoms. 

1 About twenty-five of these are taken from my own records; the remainder are 
mainly isolated cases, scattered through medical literature. The incubation is reck- 
oned from the time of exposure to the beginning of the catarrh. 
60 



930 THE SPECIFIC INFECTIOUS DISEASES. 

With the failing of the eruption and the subsidence of the catarrh, the 
communicability of measles diminishes rapidly. It is relatively feeble 
during desquamation! and soon a tier this period it usually ceases alto- 
gether. It is generally proportionate to the severity of the catarrhal 
symptoms, and when these are protracted it is probable that the disease 
may be communicated for a much longer period than that mentioned. 

Mode of Infection. — Measles is usually spread by direct contagion, 
very infrequently through the medium of clothing, furniture, or a third 
person. Measles rarely if ever clings to apartments for weeks or months, 
as does scarlet fever. Many instances are on record in which the dis- 
ease has been carried by a third person; but, after all, this rarely hap- 
pens, unless the contact both with the sick and the well child is very 
close and the interval short. It is very seldom that measles is carried 
by a physician who takes even ordinary precautions. In a case reported 
by Girom, the clothing of a patient is stated to have conveyed the dis- 
ease nineteen days after an attack, but this must be regarded as very 
exceptional. 

Lesions. — The only constant lesions of measles are those of the skin 
and the mucous membranes, chiefly of the respiratory tract. According 
to Xeumann, the process in the skin is of an inflammatory character, but 
is more superficial than in scarlet fever. There is congestion, accom- 
panied by an exudation of round cells about the small blood-vessels, and 
also about the sweat and sebaceous glands, and the papillae. To this 
exudation and the oedema, the swelling of the skin is due. It occurs 
everywhere, but is especially noticeable upon the face. 

The changes in the mucous membranes are quite as much a part of 
the disease as are those of the skin. There is a catarrhal inflammation 
affecting the conjunctivas, nose, pharynx, larynx, trachea, and large 
bronchi, which varies in intensity with the severity of the attack. In the 
most severe forms in infants and in young children, this inflammation 
extends with great uniformity to the small bronchi, and usually to the 
air vesicles, causing broncho-pneumonia. In severe cases, the lesion in 
the pharynx and larynx also, instead of being catarrhal, may be mem- 
branous; the larynx being much more frequently involved, and the ears 
much less so, than in scarlet fever. Freeman has described areas of focal 
necrosis in the liver similar to those found in diphtheria; they were 
present in four of twelve cases examined. The lesions of the lungs and 
of other organs will be more fully considered under Complications. 

The bacteria which are associated with the lesions of the respiratory 
tract are the staphylococcus and the streptococcus, separately or together, 
and either form may be associated with the pneumococcus (see Bac- 
teriology of Broncho-Pneumonia). Measles produces conditions in the 
mucous membranes of the respiratory tract which are especially favour- 
able for the development of these bacteria. They are present in the 



MEASLES. 



<M 



mouth in great numbers; they may cause pneumonia, otitis, and other 
local inflammations, and the pneumococcus or streptococcus may produce 
a general septicaemia. 

Symptoms. — Invasion. — As a rule, the invasion of measles is gradual, 
both the fever and catarrhal symptoms increasing steadily up to the ap- 
pearance of the eruption. The characteristic symptoms of the invasion 
are those of a severe coryza — suffusion of the eyes, increased lachrvma 
tion, photophobia, sneezing, and a discharge from the nose. The hoarse, 
hard cough indicates that the catarrhal process has involved the larynx 
and trachea, as well as the visible mucous membranes. Frequently the 
patient complains of some soreness of the throat, and on inspection there 
is seen moderate congestion of the tonsils, fauces, and pharynx. On the 
hard palate are frequently seen small red spots. Much more character- 
istic are the minute white spots upon the mucous membrane of the cheeks, 
known as Koplik's sign (see Diagnosis). The constitutional symptoms 
are indefinite, and may be met with in almost any disease. There are 
dulness, headache, pains in the back, and the usual symptoms of malaise; 
there is rarely vomiting or diarrhoea. Drowsiness is a frequent symp- 
tom, and is regarded by the laity as characteristic. 

The exceptional cases in which the invasion is abrupt are puzzling. 
There may be a sudden accession of fever with vomiting, and even con- 
vulsions, as in a case lately under my observation. Not infrequently, 
when the disease prevails epidemically, the invasion is sudden, with high 
fever and pulmonary symptoms which are so severe as to mask every- 
thing else until the rash makes its appearance, the case up to that time 
being often regarded as one of primary pneumonia or of influenza. The 
duration of the stage of invasion — i. e., from the beginning of the 
catarrh until the eruption — in 270 cases of which I have notes, was 
as follows: 



1 day or less 35 cases. 

2 days 47 " 

3 " 64 " 

4 " 64 " 

5 " 29 " 



6 days 20 cases. 

7 " 6 " 

8 " 2 " 

9 " 2 " 

10 " 1 case. 



From this table it will be seen that the length of the period of inva- 
sion varies considerably — more, I think, in infants and very young chil- 
dren (most of these were under three years old) than in those who are 
older. In the greater number of cases it lasts from two to four days. 

Eruption. — The rash usually appears on the third, fourth, or fifth 
day of the disease — in the largest number upon the fourth day. As a 
rule, it is first seen behind the ears, on the neck, or al the roots of the 
hair over the forehead. It appears as small, dark-red spots, which are 
at first few, scattered, and not elevated, resembling flea-bites. In twenty- 
four hours the macules are much more numerous, and many of them 



932 THE SPECIFIC tNFECTIOUS DISEASES. 

have become papules. They frequently group themselves in crescentic 
forms. They are usually separated by areas of norma] skin, but where 
the rash is intense they are frequently coalescent. From the time of its 
firsl appearance to the full development of the rash on the face, is usu- 
ally about thirty-six hours, but may be from one to three days. With 
a full eruption (Plate XVI) there is considerable swelling of the face, 
especially about the eyes; and the features are sometimes scarcely recog- 
nisable. On the second day of the rash it begins to appear upon the 
neck beneath the chin, the upper part of the chest and back; on the third 
day the trunk is covered, and scattered spots are seen upon the extremi- 
ties. The rash appears last upon the lower extremities, and by the 
time it is fully out upon them it has usually begun to fade from the 
face. In mild cases it remains discrete, but in severe ones it is fre- 
quently confluent upon the face and upon the extensor surfaces of the 
extremities. As a rule, it covers the entire body, even the palms and soles. 

The eruption fades slowly in the order of its appearance, and there 
is left behind, in typical cases, a slight brownish staining of the skin 
which often remains for a week or more. The duration of the rash is 
from one to six days, the average being four days. 

There are many cases in which the rash does not follow the typical 
course described: (1) Instead of spreading gradually, the entire body 
may be covered in a few hours. (2) The rash may be hemorrhagic. 
This condition was present in about five per cent of my cases. The 
whole eruption may be hemorrhagic, or it may be so only upon certain 
parts — usually the abdomen or extremities. Under such circumstances 
small petechial spots take the place of the macules — the " black measles " 
of the older writers. It is in most cases a bad, but by no means a 
fatal symptom. I have seen it in several cases that were not especially 
severe. (3) The rash may be very faint, and of short duration, being 
scarcely elevated at all. (4) It may consist of very minute papules, 
closely resembling the rash of scarlet fever. It is to be remembered, how- 
ever, that the irregular eruptions of scarlet fever much more frequently 
resemble measles than vice versa. (5) It may be very scanty, and late 
in its appearance; particularly in cases of great severity and hyper- 
pyrexia — the so-called malignant cases. (6) Temporary recession of 
the eruption may occur at any time during the height of the disease, and 
is usually due to heart failure. A recurrence of the eruption after it has 
run its usual course is something which I have never seen; although 
such cases have been reported, I believe them to be very exceptional. 

During the first two days of the eruption, the local and constitutional 
symptoms increase in severity, both usually reaching their maximum at 
the time of the full development of the rash upon the face. The skin 
is swollen, and the seat of intense itching and burning. The eyes are 
very red and sensitive to light, and there is swelling of the conjunctivae 



PLATE XVI. 




Eruption of Measles. 

On the face and trunk the eruption is rather more confluent than is usual : on the 
upper part of the chest, on the lower part of the abdomen, but especially on the left arm, 
many hemorrhagic spots are seen. The eruption on the lower extremities and feet is 
typical in appearance. 



MEASLES. 933 

with an abundant production of mucus or muco-pus, causing the lids to 
adhere. There is pain on swallowing, also swelling of the glands a1 the 

angle of the jaw or in the post-cervical region. The cough is Erequeni 
and very annoying. There is complete anorexia, and often diarrhoea. 
The tongue is coated, and may show at its margin enlarged papilla 1 . 
somewhat resembling the " strawberry " appearance of scarlel lever. 

As the rash fades the temperature declines rapidly, often reaching the 
normal in two or three days. The catarrhal symptoms now subside, and 
soon the patient is convalescent. Within a day or two after the fever 
has ceased, the rash disappears. 

Desquamation. — This begins almost as soon as the rash has subsided, 
and is first noticed on the "face and neck, where the eruption first ap- 
peared. The nature of the desquamation is invariably fine, branny scales, 
never in large patches, as in scarlet fever. It is often quite indistinct 
and may be overlooked. Its usual duration is from five to ten days. It 
may, however, be prolonged for two weeks. The amount of desquama- 
tion varies considerably in the different cases. It is most marked in 
those in which there has been an intense eruption. There is frequently 
noticed at this time an odour about the patient which is quite charac- 
teristic of measles. During this stage the cough often persists and the 
eyes remain weak and very sensitive to light, but in other respects the 
patient usually feels perfectly well. 

1. The Mild Cases. — The mildest cases are distinguished by low tem- 
perature, which at the height of the eruption usually reaches 102° F., but 
rarely lasts more than four days. The eruption is often scanty, and is 
never confluent. The swelling, itching, and other cutaneous symptoms 
are wanting, as is also the intense red colour of the skin. The rash is 
frequently obscure, and, without the other symptoms, hardly sufficient 
for diagnosis. The catarrhal s}-mptoms are more uniform than the rash, 
but these are very mild as compared with the usual form. The duration 
of the rash is shorter, desquamation is scarcely perceptible, and there are 
no complications. 

2. The Cases of Moderate Severity. — The course of measles is much 
more regular in children over three years old than in infancy. In the 
former, the symptoms of invasion come on gradually, and the tempera- 
ture rises steadily until the appearance of the eruption, which is in most 
cases on the third or fourth day of the disease. Figs. 186 and 187 rep- 
resent the typical temperature curve in average uncomplicated cases. 
Such a curve was seen in 14 per cent of 173 cases in which careful 
observations were made. Sometimes the decline in the fever is very 
rapid, almost a crisis, as in Fig. 186, but more often it falls gradually, 
as in Fig. 187. In such cases the duration of the fever is from five to 
nine days, the average being about a week. The other symptoms follow 
very closely the course of the fever. The maximum temperature is 



934 



THE SPECIFIC INFECTIOUS DISEASES. 



nearly always coincident with the full rash upon the face, at this time 
usually being in uncomplicated cases from 103° to 104° F. in older chil- 
dren, and 104° to 105° F. in infants and young children. 



DAY 


1 


1 


a 


4 


r> 


c 


7 


8 


t 

I 
Z 

5 

i 
< 


m 

105^ 
104° 
103" 

102" 
101" 
ioo c 

99 ' 
98° 


M E 


H E 


M E 


M E 


W E 


M E 


H E 


M E 








X 
















A 














I 


A 














\ 


\ 








/s 


./ 


J 












/ 


V 














/ 










i^ 


N 


















y 



DAY 


1 


1 


:s 


4 


E 


i; 


7 


8 


9 


E 
1 
z 
ui 
a 
I 
< 
Ik 


100° 
105° 
104 c 
103° 
102° 
101° 

ioo r 

99° 
98° 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 






X 


X 


„ 
















A 
















h 


\A 


A 
















V 


\r 












A 






V 


L 








S 


y 


J 






*^> 


v^ 








V 










1/ 


















V 


U 



Fig. 186. — Temperature Curve in Un- 
complicated Measles, Showing the 
Gradual Rise and Critical Fall. 
Patient ten years old ; x = first eruption ; 
* = full eruption on the face. 



Fig. 187. — Typical Curve in Uncompli- 
cated Measles, with Gradual Rise 
and Gradual Fall. Patient three 
years old. 



A not very uncommon temperature curve is that of Fig. 188, where 
the onset of the disease is marked by a sudden rise to 102° or even 
104° F., with a fall nearly or quite to normal on the second day, after 

which the fever rises grad- 
ually, as in the first group. 
This curve was seen in five 
per cent of my cases. 

3. The Severe Cases. — 
In Fig. 189 is shown a 
type of the disease which is 
more frequent in infants 
than in older children, the 
important features being the 
late eruption and the con- 
tinuance of the high fever 
for several days after the 
rash has begun to fade. 
Such a prolonged course and so high a temperature are almost invariably 
due to some complication, usually broncho-pneumonia. Where the pneu- 
monia goes on to the production of areas of consolidation, the fever usu- 
ally continues for three and sometimes for four weeks, even though 
terminating in recovery. 

Figs. 190 and 191 illustrate two types of the disease which are often 
seen when measles is complicated by pneumonia. In cases like that 
shown in Fig. 189 the onset is abrupt with high temperature, prostra- 
tion, and pulmonary symptoms not unlike those of primary pneumonia. 



DAY 


1 


2 


s 


i 


5 


G 


7 


s 


9 


10 


11 


12 


K 

B 

X 

z 

H 
IT 

I 
< 
U. 


106 C 
105° 
104° 
103° 
102° 
101 
lOo" 
99° 
98° 


M E 


M E 


H E 


M E 


■: E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 














X 






















X 


X 


X 




















V 


A 












\ 






n 


/ 


V 


\ 












\ 






/ 


/ 






\ 












y 




/ 


V 






\ 












\ 


\ 












v^ 


\ 


y 






V 


w 


, 












\ 


/ 





Fig. 188. — A Not Infrequent Temperature 
Curve in Measles, Showing Abrupt Invasion, 
but Subsequent Course Typical. Uncom- 
plicated case; patient nine months old. 



MEASLES. 



935 



A temperature curve resembling this was seen in 28 of L73 cases. The 
rash is often late in appearance; it is faint and altogether irregular; 
it may recede after the first day and reappear after an interval of one 
or two days. The catarrhal symptoms are not marked, but the whole 
force of the disease seems to be expended upon the lungs. The diag- 
nosis of these cases presents great difficulties, and very often it would 



day 12 3 4 5 6 7 


8 9 10 11 12 13 14 15 16 17 


M EM EM EM EMEM EM 


EM EM EMEM EM EMEMEMEM EME 


X X 


1 




1. 


1 * -k^ALMJ 


-J3a^ 


u^imj 


TV" 1 ' ^ 


C3±n£ i 


-t U^ 


z it - 


j xZUv 


z *» 


^1T\a 


98° 


\r 



Fig. 189. — Measles with Prolonged Invasion. Continuance of high temperature 
after full eruption due to severe bronchitis and diarrhoea; child two years old. 

not be made but for the fact that there are other cases of measles in 
the family or the institution. This form is usually seen in infants, and 
it is usually fatal. 

In other cases marked by a sudden severe onset, the system seems to 
be overpowered by the poison of the disease itself. There is profound 
depression, and hyperpyrexia, and the 
patient may die from toxaemia with 



DAY 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


I 
Z 

<r 

X 


106° 
105° 
104° 
103° 
102° 
101° 
100° 
99 c 
98° 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 






X 












f 


f 






A 












1 




A 


/ 




J 


J 


VI 


\f 


V 


1 




/ 


V 






V 


V 


V 


V 














V 


















y 




















I 



































DAY 


1 


2 


3 


i 


5 


t 

I 
Z 

BE 
I 
If 


108° 
107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 

99° 
98° 


m e 


M E 


M E 


M E 


M E 








Jit 


X 








flft 


f 










y 






1 




i 








I 






t 


J 








/ 








/' 


J 








/ 





















Fig. 190. — Fatal Attack of Measles, Compli- 
cated by Broncho-Pneumonia. Very severe 
symptoms from the onset; patient eighteen 
months old ; death on tenth day. 



Fig. 191, — Fatal Attack of 
Measles, Complicated by 
Broncho-Pneumonia. Early 
invasion mild, but rapid de- 
velopment of severe symptoms 
on fourth day; rash on last day ; 
patient eight months old. 



cerebral symptoms before the appearance of the rash or just as it is be- 
ginning to show itself. Sometimes the pulmonary symptoms are entirely 
wanting; at others the rash, if it appears, is haemorrhagic. 



936 THE SPECIFIC INFECTIOUS DISEASES. 

In si ill another group of cases the onset is not violent, and for the 
first two days the attack may appear to be of only average severity; but 
there may then develop, often quite suddenly, pulmonary symptoms of 
such intensity as to cause death within twenty-four hours. The erup- 
tion, if seen at all. is faint and not characteristic (Fig. 191). 

A secondary rise in the temperature after it has once fallen to nor- 
mal was seen in 8 of 173 cases, being due to the development of otitis, 
ileo-colitis, or pneumonia. 

Complications and Sequelae. — The most frequent and most important 
complication of measles is broncho-pneumonia, and next to this are ileo- 
colitis, otitis, and membranous laryngitis. Most of the others are in- 
frequent; all complications are relatively rare in children over four 
years old. 

Lungs. — The greatest danger in measles arises from pulmonary 
complications, and the frequency is greatest in children under two years 
of age. In two epidemics in the Nursery and Child's Hospital, em- 
bracing about 300 cases, nearly all in children under three years old, 
broncho-pneumonia occurred in about 40 per cent of the cases. Of those 
who had pneumonia, 70 per cent died. Fortunately, such a record as 
this is never seen outside of asylums or hospitals for young children. 
Of 2,477 cases, embracing several epidemics of measles among children 
of all ages, pneumonia occurred in 10 per cent. My own experience in 
the post-mortem room fully bears out the statement of Henoch, that a 
certain amount of pneumonia is found in almost every fatal case. Pneu- 
monia is more frequent and its mortality is higher in spring and winter 
epidemics than in those occurring at other seasons. It may develop at 
any time from the beginning of invasion until convalescence, but it 
most frequently begins about the time of full eruption. 

Lobar pneumonia, although rare, occasionally occurs as a complica- 
tion in children over three years old. In some epidemics many of the 
cases of pneumonia are complicated by severe pleurisy, which adds much 
to the danger from the disease. This form is frequently followed by 
empyema. Pneumonia is always to be suspected when the temperature 
continues high after the full appearance of the rash. 

Bronchitis of the large tubes, always accompanied by tracheitis, is 
seen in every case of measles, possibly excepting a few of the very 
mildest. This is so constant a feature as hardly to be ranked as a 
complication. In nearly all of the severe cases the bronchitis extends 
to the medium-sized and smaller tubes. 

Larynx. — A mild catarrhal laryngitis accompanies almost every case 
of measles:. Severe' catarrhal laryngitis is present in about ten per cent 
of the eases; it may give symptoms which closely resemble those of 
membranous laryngitis, and the two are no doubt often confused. 

Membranous laryngitis is especially seen in the epidemics of insti- 



MEASLES. 

tutions. As a cause of death in older children it ranks next to pi. 
monia. When it develops at the heigh* of the disease, it is sometu 
due to the streptococcus; but when it develops at a later period, it is 
usually due to the diphtheria bacillus. The streptococcus inflamma- 
tion is in most cases associated with similar changes in the pharynx or 
tonsils, but not always. True diphtheria, occurring as a complieation 
of measles, not infrequently begins in the larynx. The streptococcus 
inflammation may be as serious in this connection as is true diphtheria, 
from the probability, which amounts almost to a certainty, of the devel- 
opment of broncho-pneumonia. Xo complication is more to be dreaded 
than this. The diagnosis between the true and pseudo-diphtheria may 
sometimes be made by the time of development, but only with certainty 
by cultures. I once saw in measles, where no false membrane was present 
in the rest of the larynx, a necrotic inflammation with almost entire 
destruction of the vocal cords — a condition which may be compared to 
that seen in the tonsils or epiglottis in scarlatina. 

Tiiroat. — A catarrhal angina is part of the disease, and is as charac- 
teristic of measles as is the eruption upon the skin. There is acute con- 
gestion and swelling of the tonsils, uvula, palate, and pharynx. In a 
certain proportion of cases, very much less frequently than in scarlatina, 
the development of membranous patches is seen upon the tonsils and ad- 
jacent mucous membranes. These occur in two or three per cent of the 
cases. They are to be regarded in the same light as similar conditions 
complicating scarlet fever, with these differences, that in measles there 
is much greater likelihood of the extension of the disease to the larynx, 
while extension to the nose and ears is much less probable. True diph- 
theria, however, may complicate measles, and cases of membranous in- 
flammation of the tonsils or pharynx developing late in measles are 
usually due to the Klebs-Loeffler bacillus. 

Although in most cases the inflammations of the pharynx and ton- 
sils which accompany measles are not serious when they are due to the 
streptococcus, they are sometimes quite as severe as any that accompany 
scarlet fever. They may cause death from general sepsis apart from any 
affection of the larynx. 

Digestive System. — Gastric disorders are not more common than in 
other febrile diseases : but diarrhoea is very frequent, and in summer it 
may be even more serious than the pulmonary complications. All forms 
of diarrhoea are seen, from that which results from simple indigestion 
to the severe types of ileo-colitis. This complication is most often seen 
in children under two years old. The most severe intestinal symptoms 
are not usually seen at the height of the primary fever; but, beginning 
at this time, they often increase in severity, and are most marked in the 
second and third weeks of the disease. 

Catarrhal stomatitis is present in almost every case of measles; less 



938 THE SPECIFIC INFECTIOUS DISEASES. 

frequently the herpetic form is Been. Ulcerative stomatitis is not uncom- 
mon, particularly in institutions. One of the worst complications of 
measles, but fortunately a rare one, is gangrenous stomatitis, or noma. 
This usually occurs in inmates of institutions, or in children with bad 
surroundings who were previously in wretched condition. It is nearly 
always fatal. 

Gangrenous inflammations of other parts of the body are sometimes 
seen after measles, espeeially of the ear, the vulva, or the prepuce. 

Nervous System. — I have seldom seen convulsions at the onset of 
measles. During the progress of the disease they are not so rare, and 
may occur in connection with otitis, meningitis, or severe broncho- 
pneumonia — chiefly in infants. 

Meningitis is rare, but either the simple or the tuberculous form 
may occur, more often, however, as a sequel than as a complication. 
Insanity, usually of a temporary character, occasionally follows measles. 
In the epidemic of 108 cases reported by Smith and Dabney, insanity 
was noted three times, all the cases terminating in recovery. Epilepsy 
and chorea are rare sequelae. 

Ears. — Otitis is a frequent complication in some epidemics ; in others 
it is seldom seen. In one hospital epidemic it was noted in l± per cent 
of the cases. This epidemic occurred in early spring and affected very 
young children, both of which circumstances are favourable for the 
development of otitis. Usually both ears are affected, but the otitis of 
measles is, as a rule, less serious than that of scarlet fever. 

Eyes. — Simple catarrhal conjunctivitis accompanies nearly every case 
of measles. In the severe form there is a muco-purulent catarrh, which 
may attain any degree of severity. In neglected cases, and among chil- 
dren who are poorly nourished, especially in asylums, the disease is apt 
to extend to the cornea. Chronic conjunctivitis often persists after 
measles, particularly in the class of children just mentioned. 

Lymph Nodes. — Swelling of the lymphatic glands of the neck is 
frequent, but not generally severe, and rarely terminates in suppuration. 
Chronic enlargement may continue for months, and sometimes the glands 
may become tuberculous. Similar changes and similar consequences 
may occur in the glands of the tracheo-bronchial group. 

Kidneys. — The infrequency of renal complications in measles is in 
striking contrast to scarlet fever. Transient febrile albuminuria is not 
uncommon, but a serious degree of nephritis, either clinically or at 
autopsy, I have never seen, and literature furnishes but few cases. 

Heart. — Both endocarditis and pericarditis have occurred in the 
course of measles, but they belong to the rare complications. The same 
may be said of changes in the muscular walls of the heart. 

Skin. — As complications, erysipelas, furunculosis. impetigo, and 
pemphigus have been noted; but all are rare. 



MEASLES. 939 

Hmmorrliages. — Associated with the hemorrhagic type of the erup- 
tion, severe and even fatal haemorrhages may occur from the mucous 
membranes, and the latter are sometimes seen without the hemorrhagic 
eruption. 

Blood. — There is a leucocytosis of 15,000 to 30,000 beginning 
after infection, even before the invasion, and increasing for four or five 
days. During the eruption the number of leucocytes falls gradually to 
normal or below. A marked leucocytosis at this time or later points to 
a complication, but its absence during eruption does not exclude one. 
The differential count shows the increase to be in the polymorphonuclear 
cells. 

Other Infectious Diseases. — Measles in institutions is often compli- 
cated by diphtheria. Scarlet fever or varicella occasionally occurs during 
measles, though it is rare that the two eruptions are exactly simultaneous. 
Epidemics of measles and whooping-cough frequently occur together or 
follow each other. The relation of measles to tuberculosis seems to be 
particularly close. In some cases general or pulmonary tuberculosis 
follows directly in the wake of measles, which seems to furnish, espe- 
cially in the lungs, conditions which are favourable for the development 
of latent tuberculosis. As a late manifestation the most common one 
is tuberculosis of the bones, occurring as hip- joint disease, caries of the 
spine, etc. An attack of measles in a child with tuberculous antecedents 
should, therefore, always be looked upon with apprehension. 

Diagnosis. — A sign of the greatest diagnostic value is the buccal erup- 
tion. Although it appears that this was described many years ago by 
Mindt, of Denmark, it is to Koplik, of New York, that the credit belongs 
of its independent discovery and publication in 1896. It is generally 
known as " Koplik's sign." The unit of the eruption is a bluish-white 
speck upon a red ground; only a few of these may be present or the 
mucous membrane may be fairly peppered with them (Plate XVII). 
Often they are not seen except by careful search, for which strong sun- 
light is necessary; artificial light is not satisfactory. The spots are 
best seen on the inside of the cheeks opposite the molar teeth, and in 
most cases only there; but they may be present on almost any part of 
the buccal mucous membrane. Their diagnostic value is due to the fact 
that they are nearly always present, that they are not found in other 
diseases, and that they usually appear two or three days before the skin 
eruption. They generally disappear at the time of full eruption. 

I have recently had an opportunity to study the value of this sign in 
two epidemics of measles at the New York Foundling Hospital. Care- 
ful notes were kept in the second epidemic of 187 cases. Koplik's spots 
were unmistakably present in 169 cases, absent in 8, doubtful in 10. 
In 78 cases, fever, rash, and Koplik's spots were all present at the first 
observation. In 54 patients the sign was noted one day before the rash ; 



i)40 THE SPECIFIC [NFECTIOUS DISEASES. 



mi 25, two davs before; in i, three days before; in 3, four days before; 
and in 8, five days before. In 2 the Bpots were not Been until after the 
skin eruption: in one ease they were present without any eruption. As 
this patient had been exposed and had a prolonged fever, it seems Eair 
_ard the case as one of measles. In only one ease was the buccal 
eruption seen before any elevation of temperature. 

These facts, amply ion tinned by other observations, indicate that 
Koplik's sign is of value in enabling us to make a diagnosis from one 
to three days before it is possible by the skin eruption, also in furnish- 
ing a new means of distinguishing measles from the other eruptive 
levers, as well as from rashes due to drugs, antitoxine, etc. 

Other important symptoms are the coryza, the gradual rise in tem- 
perature, and the eruption which appears first upon the neck and face, 
and slowly extends over the body. Cases which present the greatest diffi- 
culties in diagnosis are usually the very severe ones and those in infants. 

Prognosis. — This depends upon the age and previous condition of 
the patient, the character of the epidemic, and the season of the year. 
Except in children under three years of age, the deaths from measles 
are few; but in institutions containing young children, no epidemic 
disease is so fatal. 

The general mortality of the disease is from 4 to 6 per cent; but in 
epidemics in institutions for young children it has, in my experience, 
ranged from 15 to 35 per cent. The following table gives the figures of 
an epidemic in one institution: 

From six to twelve months 42 cases; mortality, 33 per cent. 

" one to two years 51 " 50 " " 

" two to three years 27 " ■ " 30 " " 

" three to four years 20 " " 14 " 

" four to five years 3 " " " " 

In any single case the important symptoms for prognosis are the 
temperature and the character of the eruption. An initial temperature 
above 103° F., or one which remains high until the eruption appears, is 
a bad symptom. So also is one which rises after a full eruption, or 
which does not fall as the rash fades. The following table shows the 
highest temperature and mortality in 161 hospital cases: 

Highest temperature not over 102° F. . 6 cases; mortality, per cent. 
102° to 103.5° F.. 14 " " 7 " 

104° " 104.5° F.. 49 " " 16 " 

105° " 105.5° F . . 65 " " 40 " 

106° F. or over .27 " " 80 " 

A favourable eruption is one of a bright colour, covering the body, 
remaining discrete, and spreading gradually. It is unfavourable for the 
eruption to appear late, to be very faint, scanty, or hemorrhagic, or to 
recede suddenly, as this is usually due to a weak heart. 



PLATE XVII. 





The Buccal Eruption of Measles (Koplik's Spots). 

A. This represents the earliest stage; the spots are few, rather large, widely sepa- 
rated, and usually show a distinct areola: the mucous membrane is normal in color. 

B. The later appearance and that most frequently seen. 

Near the center of the field the spots are closer together, although still remaining 
individually distinct; the mucous membrane is somewhat congested. At the margin 
of the field they are fainter and lack the areola, representing a still later period, such 
as is seen before they disappear altogether, although in some cases they are not more 
distinct than this at' any stage. 



MEASLES. [)]] 

Of 51 fatal cases, the cause of death was broncho-pneumonia in l.*>, 
ileo-colitis in 4, and membranous laryngitis in 2. More than half the 
deaths occurred during the second week, the earliest being upon the; 
fifth day of the disease. 

The ultimate result of an attack of measles may not be evident for 
some time. Cases in which the temperature persists for two or three 
weeks without assignable cause after the disease is apparently over, 
should be watched with the greatest solicitude. The explanation of this 
is most frequently to be found in the lungs, although the physical signs 
are often obscure. The condition may be either subacute pneumonia 
or pulmonary tuberculosis. Even though the attack of measles may not 
have been in itself severe, seeds are often sown the full fruits of which 
are not seen until long afterward. Chronic glandular enlargements 
which may or may not be tuberculous, chronic bronchitis, chronic laryn- 
gitis, subacute or chronic nasal catarrh, hypertrophy of the tonsils, and 
adenoid growths of the pharynx — all are frequent sequelae. 

Prophylaxis. — Measles is often regarded by the laity as so mild a 
disease that its prevention is thought to be of little importance, and no 
effort is made to limit its extension. The great probability that every per- 
son at some time in his life will have the disease, is no justification of un- 
necessary exposure. Although in older children measles is usually mild, 
this is not so in infants, who should be carefully protected from exposure. 
Special care should also be taken to avoid the exposure of delicate chil- 
dren or those with a strong tendency to pulmonary disease or to tuber- 
culosis. In institutions it is of the utmost importance to secure prompt 
and complete isolation of the first case which appears. 

The disease being usually spread by the patient and rarely from 
apartments, it follows that while early isolation is more important, 
there is not required the same thorough cleansing and disinfection which 
should follow every case of scarlet fever. In an institution, the ward or 
cottage from which a case has been removed should be quarantined for 
at least sixteen days after the appearance of the last case, and absolute 
security can not be said to exist until the end of three weeks. The same 
rule should be applied in private families where children who have been 
exposed should be quarantined apart from the patient, but not sent away. 
Under ordinary circumstances the quarantine of a case of measles should 
last three weeks from the beginning of invasion. It should be continued 
longer if there is pneumonia, otitis, or a nasal discharge. 

Thorough cleansing and disinfection of the sick-room should be done 
before it is again occupied by children, and it should remain vacant 
at least two weeks. Children should be kepi from all schools while 
the disease is in their homes, chiefly because they are otherwise li- 
able to spread the disease while suffering from the early symptoms of 
invasion. 



942 THE SPECIFIC INFECTIOUS DISEASES. 

Treatment.— Measles is a self-limited disease, and there are no known 

measures by which it can be aborted, its eourse shortened, or its severity 

ed. The indications are therefore to treat serious symptoms as 

they arise, and. as far as possible, to prevent complications, which are 

the principal cause of death. 

The sick-room should he darkened, as the eyes are very sensitive to 
light. Every child with measles should be put to bed and kept there with 
light covering during the entire febrile period. There can be no possible 
advantage in causing a child to swelter by thick covering, under the delu- 
sion that the disease may be modified thereby. The food should be light, 
fluid, and given at regular intervals. If the conjunctivitis is severe, iced 
cloths should be applied to the eyes, which should be kept clean by the 
frequent use of a saturated solution of boric acid, the lids being prevented 
from adhering by the. application of vaseline or simple ointment. The 
intense itching and burning of the skin may be relieved by inunctions 
of plain or carbolised vaseline, or by bathing with a solution of bicar- 
bonate of soda. The cough, when distressing, may be allayed by small 
of opium, either in the form of codeine or the brown mixture. The 
restlessness, headache, and the general discomfort which accompany the 
height of the fever may be relieved by an occasional dose of phenacetine 
or antipyrine. As soon as the rash has subsided, a daily warm bath 
should be given, followed by inunctions to facilitate desquamation and 
prevent the dissemination of the fine scales. 

The important indications to be met in the severe cases are very 
high temperature, cardiac depression, and nervous symptoms — dulness, 
stupor, sometimes coma, or convulsions. In some of the cases there is 
in addition dyspnoea and cyanosis, showing severe acute pulmonary con- 
gestion. For the nervous symptoms and high temperature, nothing is so 
reliable as the cold bath or pack and the nearly continuous use of ice 
to the head. I do not think there is any evidence that the use of cold 
increases the Liability to pneumonia; but cold extremities, feeble pulse, 
and cyanosis, when associated with high temperature, call for the hot 
mustard bath, although ice should still be applied to the head. The indi- 
cations for stimulants and the methods of using them are the same as in 
broncho-pneumonia, which is usually present in cases requiring them. 

To diminish the chances of pneumonia, it is necessary that every 
patient should be kept in bed during the attack, and care exercised to 
avoid exposure. But still more important is it in hospitals and institu- 
tions where most of the cases of pneumonia occur, to allow the patients 
plenty of air space, never crowding them together in small wards. If 
Je, cases complicated by pneumonia should be separated from sim- 
ple cases. The pneumococcus and the streptococcus are found in the 
mouth in such numbers that systematic disinfection of the mouth may 
prove of some value. 



RUBELLA. <.(};; 

The danger of diphtheria as a complication may be greath 
if during epidemics of measles in institutions every ease receive 
immunising dose of diphtheria antitoxine. 

The bronchitis and broncho-pneumonia of measles should be man- 
aged as when they occur as primary diseases, since the coexistence of 
measles furnishes no new indications. The same is true of the diarrhoea, 
conjunctivitis, otitis, membranous laryngitis, pharyngitis, and tonsillitis. 
Should cultures show the presence of the diphtheria bacillus, th< 
should be treated like one of diphtheria. 

During convalescence the eyes should be used very carefully for at 
least several weeks. Should the cough and slight fever persist, with or 
without physical signs in the chest, the patient should, if possible, be 
sent away to a warm, dry, elevated district, as the development of 
tuberculosis is always to be feared. Cod-liver oil should be given con- 
tinuously throughout the succeeding cool season, and iron, wine, and 
other tonics according to indications. The cough itself should be treated 
as when it follows an ordinary bronchitis, creosote being more generally 
useful than any other drug. 



CHAPTER III. 

RUBELLA. 
(German Measles; Rotheln.) 

Rubella is a contagious eruptive fever which is rarely seen except 
when prevailing epidemically. It is characterised by a short invasion, 
with mild, indefinite symptoms, usually lasting but a few hours, and by 
an eruption which is generally well marked but of variable appearance. 
The constitutional symptoms are very mild, and the disease rarely proves 
fatal, not often being even serious. For a long time rubella was con- 
founded with measles and scarlet fever, as the eruption sometimes resem- 
bles one and sometimes the other disease. Its identity is now fully estab- 
lished, and, as Strumpell well says, its existence is doubted only by those 
who have never seen it. 

Eubella is a contagious, eruptive fever, and not a simple affection of 
the skin; it prevails independently either of measles or of scarlet fever; 
its incubation, eruption, invasion, and symptoms differ materially from 
those of both these diseases; it attacks indiscriminately and with equal 
severity those who have had measles and scarlet fever and those who 
have not, nor does it protect in any degree against either of them : it 
never produces anything but rubella in those exposed to its contagion ; 
it occurs but once in the same individual. 

Etiology. — Eubella is beyond question contagious, but is decidedly 
less so than either measles or scarlet fever: so that some observers 



944 THE SPECIFIC tNFECTIOUS DISEASES 

have doubted its contagion altogether. It can be communicated at 
any time during its course, but is especially contagions during the 
early stage. Epidemics usually prevail in the winter or spring. As 
in the other eruptive fevers, a striking immunity is seen in infants 

under six months old: but, with this exception, all ages are liable to the 
disease. 

The incubation of rubella varies considerably; the usual period is 
from fourteen to twenty-one days, although the limits are from ten to 
twenty-two days. 

Symptoms. — Invasion. — This is rarely more than half a day, and in 
many cases no prodromata whatever are noticed, the rash being the first 
thing to attract attention. In a few cases there are mild catarrhal symp- 
toms, with general malaise and slight fever. At other times there may 
be vomiting, convulsions, delirium, epistaxis, rigors, headache, or dizzi- 
ness ; but all are to be regarded as very exceptional. 

Eruption. — Frequently a child wakes in the morning covered with 
the rash, no symptoms having been previously noticed. It generally ap- 
pears first upon the face, and spreads rapidly to the whole body, the lower 
extremities being last covered. Less than a day is usually required for 
its full development. Exceptionally the eruption comes first upon the 
chest and back, and sometimes nearly the whole body is covered almost 
at once. The rash is occasionally observed in the roof of the mouth 
before it is visible on the face. In a considerable number of cases the 
entire body is not covered ; but the rash is more constantly seen upon the 
face than upon any other part of the body. 

Its character is subject to considerable variation. The eruption is 
most frequently composed of very small maculo-papules ; they are of a 
pale-red colour, and vary in size from a pin's head to a pea. The spots 
are usually discrete, but may cover the greater part of the body where it 
is seen. On the face it is frequently confluent, and often appears here 
as large, irregular blotches of a red colour. From this description the 
rash will be seen to resemble that of measles more than that of any other 
disease. Very often, however, there is a fairly uniform red blush 
which bears a close resemblance to the rash of scarlet fever ; but even in 
such cases there will nearly always be found upon some part of the body, 
usually the wrists, fingers, or forehead, some typical maculo-papules. 
Between these two extremes all variations are seen. The colour of the 
eruption is sometimes dark red, and rarely it has been noted to be hemor- 
rhagic. The degree of elevation above the surface is also variable ; some- 
times this is so marked as to give to the skin a " shotty " feel, while in 
others the elevation is scarcely perceptible. The duration of the erup- 
tion is usually three days. Occasionally it lasts only two days, and it may 
last but one; it is rare for it to remain as long as four days. It fades 
in the order of its appearance, and more rapidly than the eruption of 



RUBELLA. 945 

measles. A slight brown pigmentation of the skin BOmetimefl remains 
for a few days after the rash. 

The highest temperature is coincident with the lull eruption; tins 
does not usually exceed H>1°, and often it is only 100 1". As a rule, 
the temperature continues hut two days, falling as the eruption fades. 
Very often the fall to normal is abrupt. Rarely more severe cases are 
seen in which the fever lasts for two or three days, being ioi° or 102 1". 
during the invasion, and rising to 1<>:>° F. or more during the full erup- 
tion. The other symptoms are in most cases even less marked than the 
fever. Occasionally catarrhal symptoms resembling a mild attack of 
measles are present, or a sore throat suggesting mild scarlet fever; but 
more frequently all these symptoms are absent. The eruption is usually 
out of all proportion to the other signs of disease. 

Swelling of the post-cervical glands is one of the most constant fea- 
tures of rubella. In most epidemics it is seen in nearly all cases: hut 
as a symptom for differential diagnosis it is not of great importance as 
it is not uncommon in measles and scarlet fever. The glandular swelling 
is most marked at the height of the disease; it is never very great, and 
subsides slowly without suppuration. Vomiting and diarrhoea are rare. 
Swelling and itching of the skin are usually present and sometimes 
marked. There is no leucocytosis in this disease. 

Forchheimer has described an eruption on the mucous membrane of 
the throat, or " enanthem," which he believes to be characteristic. It 
consists of minute, bright, rosy-red points, seen on the uvula and soft 
palate, rarely on the hard palate. It is present only in the first twenty- 
four hours. 

Desquamation. — This is exceedingly variable. It is sometimes en- 
tirely wanting; writers who have observed some fairly typical epidemics 
have stated that it did not occur. In most cases, however, sonic des- 
quamation is present, though it may be so slight as to be discovered only 
by a close examination. It is usually in the form of fine scales over the 
body and extremities. In a few cases it is more pronounced, and may 
be in larger flakes or patches. 

Prognosis. — There are few diseases so free from danger as rubella. 
Complications and sequelae are very seldom seen, and when present are 
usually of the mildest character. 

Diagnosis. — The principal interest attaching to rubella is in its diag- 
nosis. This is a matter of extreme difficulty, and often it is an impossi- 
bility. The characteristic thing about the disease is a well-marked erup- 
tion with very few other symptoms. Cases so closely resemble mild 
scarlet fever that the differentiation by symptoms may he Impossible; it 
must be made by the circumstances under which it occurs, especially a 
prevailing epidemic. Scarlet fever with a low temperature and abundant 
rash should always be regarded with suspicion; also an abundant rash 
61 



940 TllK SPECIFIC INFECTIOUS DISEASES. 

with little or do desquamation. The longer period of incubation in 
rubella may be of assistance, Koplik's spots furnish a valuable means of 
distinguishing measles from rubella. These difficulties in diagnosis can 
be appreciated only by one who lias seen epidemics of measles and scarlet 
fever in institutions, and lias watched the mild course of undoubted 
rases o( these diseases which have there occurred. 

It is always hazardous to make the diagnosis of rubella unless the 
disease is prevailing epidemically. Sporadic eases in which this diagnosis 
is made are. 1 believe, almost invariably instances of mild measles or 
scarlet lever. The first eases of rubella in an epidemic are usually over- 
looked. The continued absence in succeeding cases of the characteristic 
symptoms and complications of measles or scarlet fever should suggest to 
the physician that he is probably dealing with rubella. 

Treatment. — Xone whatever is required for the disease excepting 
isolation, which should be complete until the diagnosis is positively deter- 
mined ; after this it is hardly necessary. The individual symptoms and 
complications are to be treated as they arise. 



CHAPTER IV. 

VARICELLA. 

(Chicken-pox.) 

Varicella is an acute, contagious disease, characterised by a cuta- 
neous eruption of papules and vesicles and by mild constitutional symp- 
toms, serious complications and sequelae being very rare. Although long 
confounded with varioloid, its existence as a distinct disease has been 
generally admitted for many years. 

Etiology. — It is well established that the contagium of the disease is 
contained in the vesicles, as it may be communicated by inoculation with 
their contents. The specific poison, however, has not yet been isolated. 
Varicella is contracted by exposure to another case or through the me- 
dium of a third person. It affects children of all ages, one attack being 
as a rule protective. It is very contagious, resembling measles in this 
respect. The period of incubation is quite uniformly from fourteen to 
sixteen days. 

Symptoms. — Slight fever and general indisposition may be noticed 
for twenty-four hours before the appearance of the eruption, but in most 
cases the eruption is the first symptom. It usually appears first upon 
the face or trunk, as small, red, widely scattered papules. The papules in 
most cases come in crops, new ones continuing to appear for three or 
four days, even upon the same part of the body. The earlier ones have 
generally begun to dry up by the time the later ones appear, so that all 



VARICELLA. 947 

stages of the eruption may be present at one time in the same i- 
this being one of the diagnostic features. The papules arc at firsl verj 
small, but gradually increase in size, and are Burrounded by an areola 
from one-fourth to half an inch in width. Many of them go do Further 

than this stage, but the majority become vesicular. The vesicles are usu- 
ally flat, and vary a good deal in size — the largest being about one-fourth 
of an inch in diameter. The process of drying up generally begins at the 
centre, which causes a slight depression, giving the vesicle a somewhat 
umbilicated appearance. The areola is most distinct at the time of the 
fully formed vesicle, and fades as the latter dries. Crusts now form, 
which fall off in from five to twenty days, depending upon the depth to 
which the skin has been involved. In the majority of cases no mark i> 
left, but after the most severe attacks, when the true skin has been in- 
volved, scars remain, and occasionally there is quite deep pitting. Such 
marks are few in number, and are most likely to occur upon the face. 

Sometimes, especially upon hands and feet, the vesicle appears with- 
out having been preceded by a papule; often there is no areola, and the 
vesicle resembles a drop of water upon healthy skin. In most cases pus- 
tules are not seen, but they may develop in consequence of irritation or 
infection, the result of scratching, or in children who are poorly nour- 
ished. Under these circumstances deeper ulceration may occur, lasting 
for weeks. In rare cases there may be a necrotic inflammation about the 
site of the pock, a condition to which is sometimes given the name vari- 
cella gangrenosa. It is not peculiar to varicella, and is described else- 
where under the head of Gangrenous Dermatitis. 

The pocks are usually most abundant over the back and shoulders. 
In mild cases only twenty or thirty may be found upon the entire body, 
but in severe cases the skin in certain regions may be nearly covered. 
The eruption is never confluent. The pocks are usually seen on the 
hairy scalp, and often on the mucous membrane of the mouth or pharynx 
— a point of some diagnostic value. In the latter situation the appear- 
ance is first as a tiny vesicle, and later as a superficial ulcer resembling 
that of herpetic stomatitis. Marfan and Halle have described cases of 
varicella of the larynx. Croupy symptoms were present, and in one 
case which proved fatal from pneumonia a tiny ulcer was found on the 
vocal cords. 

The temperature is highest when the eruption is most rapidly appear- 
ing, this usually being the second or third day. In an average ease it 
reaches only 101° or 102° F., and lasts but two days: in severe cat 
may rise to 104° or 105° F., and lasts for four or five days. It falls grad- 
ually to normal as the rash fades. The other symptoms are mild and 
not characteristic. 

Complications. — The most important complication is erysipelas, 
which develops about the pocks, particularly when they are deep and at- 



948 THE SPECIFIC INFECTIOUS DISEASES. 

tended with Borne ulceration. I have known of throe fatal cases from this 
cause. Adenitis, either simple or suppurative, and abscesses in the cel- 
lular tissue, are occasionally seen. Nephritis is very infrequent, but a 
number of rases are recorded. It may occur at the height of the dis- 
ease, hut more often at a later period, like the nephritis of scarlet fever. 
Varicella is quite frequently complicated by other infectious diseases. In 
the New York Infant Asylum epidemics of varicella and scarlet fever at 
one time occurred together, and in at least a dozen children both diseases 
were seen at the same time. 

Diagnosis. — The diagnosis of varicella is usually easy, provided the 
following points are kept in mind : first, that the eruption comes out 
slowly and in crops, so that papules, vesicles, and crusts may be seen upon 
the skin in close proximity; secondly, that the umbilication is due only 
to the mode of drying up of the vesicle, which begins at the centre; 
thirdly, the appearance of the pocks upon the mucous membranes, and 
the history of exposure. It is distinguished from urticaria and other 
forms of skin disease by the presence of fever. 

Treatment. — Although it is usually a trivial disease, isolation of cases 
of varicella should be enforced in schools and in institutions containing 
many infants. In the home, unless the other children are delicate or in 
poor condition, quarantine is unnecessary. The disease may probably be 
conveyed as long as the crusts are present, hence isolation should be 
maintained until they have fallen off. In most cases constitutional 
symptoms of the disease are so mild as to require no treatment. 

Locally, the itching, when annoying, may be allayed by sponging 
with a solution of bicarbonate of soda, a one-per-cent solution of car- 
bolic acid or the use of carbolised vaseline. When the crusts have formed, 
this ointment or vaseline containing two per cent ichthyol should be 
applied. Care is necessary to keep the skin clean, and, in the case of 
infants, to prevent scratching. In severe cases the urine should in- 
variably be examined. 



CHAPTER V. 
VACCINIA— VACCINATION. 

Vaccinia (cowpox) is a febrile disease induced in man by inocula- 
tion \\i1h the virus obtained either directly from the cow (bovine virus) 
or from a person who has been inoculated (humanised virus). The dis- 
ease is not contagious in the ordinary sense of the term, but is communi- 
cated by inoculation either accidental or intentional. 

The nature of the protection against smallpox which vaccination 
affords is even now but imperfectly understood. The fact, however, re- 



VACCINIA. 



949 



mains one of the best attested in medical history. Its effect when ays 
tematically practised is graphically shown in the accompanying char! 

(Fig. l!)'i). It is the imperative duty of the physician to see to it thai 
every young infant is vaccinated. 



PRUSSIA. 



ITH COMPULSORY VACCINATION, AND 

COMPULSORY RE-VACCINATION 

AT THE AGE OF 12. 



After the law of 1874 

was passed. 



1808-1874 

Average 

yearly Deaths 

from small- 
pox in every 

100,000 
Inhabitants 



IL^illii^ 



Annual Deaths 

from small-pox 

in every 100,000 

.Inhabitants. 



HOLLAND. 

WITH COMPULSORY VACCINATION OF CHILDREN 
BEFORE ENTERING A SCHOOL. 



After rte Law of 1873 



1860-1872 

Average 

yearly Deaths 

from small* 

pox in every 

100,000 
Inhabitants. 



ll 



LxjJ 



AUSTRIA. 



LtL 



[-'B JIG- :i r- — .- 

Annual Deaths 

from small-pox 

In every 100,000 

Inhabitants. 



.110 



_10O 



1808-1874 
Average 
yearly Deaths 
from small- 
pox in every 

100,000 
inhabitants. 



Annual Deaths 

from suial'.-pox 

in every 100,000 

Inhabitants. 



802 

1 

3 

1 

70 J 

1 

§ 



_ 60 



i 

L 50Q 



Fig. 192. — Table Showing the Protective Power of Vaccination. (Carsten.) 



Re-vaccination. — Kegarding the duration of the protective power of 
a single vaccination, positive statements are impossible. Nearly all 
writers are agreed that vaccination should be done in infancy, again at 
puberty, and a third time at about the age of twenty or twenty-five. 
Many also insist upon re- vaccination at about the seventh year. It is a 
safe rule when smallpox is prevalent to vaccinate every person who lias 
not been successfully vaccinated within five years. 



950 THE SPECIFIC INFECTIOUS DISEASES. 

Choice of Lymph. — The substitution o( bovine for humanised virus 

is now well-nigh universal. It has precluded the possibility of trans- 
mitting syphilis and greatly lessened the chances of other forms of in- 
fection. A further advance has lately been made by the introduction of 
"glycerinated " lymph. As now prepared, the lymph is taken from the 
calves under the most rigid aseptic precautions and emulsified with 
glycerin. The few saprophytic bacteria present soon die, so that when 
properly prepared the glycerinated virus is practically sterile. It should 
not be distributed until it has been carefully tested for pathogenic organ- 
isms of all kinds, particularly the tetanus bacillus. It is preserved and 
distributed in capillary tubes hermetically sealed; these are much safer 
than quills or ivory points, which may easily become contaminated by 
handling. After the lymph has been taken, the calves are killed in order 
to make certain that they were free from disease. The practical advan- 
tages of glycerinated lymph are so great that it has been officially 
adopted by the Governments of the United States, Great Britain, Ger- 
many, and many other countries. 

Time for Vaccinating. — In selecting a time for vaccination, the child's 
age and general health must be taken into consideration. It is pretty 
well established that the constitutional disturbance is much less in in- 
fancy than in later childhood, and less in very young infants (under one 
month) than in those of five or six months. A good rule for general 
practice is to vaccinate every healthy infant as soon as its nutrition is 
established, this being in most cases during the first three months of 
life. In delicate infants or in those whose nutrition is a matter of 
great difficulty, those who are syphilitic, those suffering from eczema or 
any other form of active skin disease, vaccination should be deferred 
until the child is in good condition, unless it is likely to be exposed to 
smallpox. As a rule, vaccination should be avoided during dentition. 

Methods of Vaccinating. — In my experience it is better to vaccinate 
in one place rather than to make two or three inoculations. If more than 
one is made they should be at least an inch apart. Either the leg or the 
arm may be chosen; in young infants it is usually easier to protect the 
vaccine sore upon the leg than upon the arm; in children old enough 
to run about, the arm is to be preferred, as being more easily kept at rest. 
The point selected for inoculation should be either the outer aspect of the 
left calf, about the junction of the middle with the upper third of the leg, 
or, if the arm is chosen, the insertion of the left deltoid. The skin should 
be washed with soap and water, dried, and then washed with alcohol. 

The New York Health Department supplies with each tube of lymph, 
a needle, a bit of rubber tubing, and a sterilised tooth-pick with one flat 
end. The needle should be sterilised in an alcohol flame, and a single 
scratch made not more than one-eighth of an inch long, just deep enough 
to draw blood. The ends of the capillary tube are broken off, one end 



VACCINIA. <j;,l 

inserted in the rubber tube, and the lymph blown nut of the tube upon 

the broad end of the tooth-pick, then applied to the scratched surface 
and rubbed in for a full minute. The wound should not be covered 

until dry: this usually requires from fifteen to twenty minutes. It may 
then be covered with a sterilised bandage. If thoroughly dried no dress- 
ing is necessary. The limb should not he washed for twenty-four 
hours. 

The Normal Course of Vaccinia. — The course of a proper vaccination- 
pock is quite uniform, and one which does not follow this course should 
not be considered protective. The wound heals and nothing is noticed 
until the third or fourth day, when a red papule makes its appearance. 
Usually in twenty-four hours more a small vesicle appears which enlarges 
until the sixth or seventh day, reaching its full development about the 
ninth day. Its shape and size depend somewhat upon the scarification 
( Figs. 193-19?). The vesicle is usually from one-fourth to one-half inch 
in diameter; it is of a pearly gray colour and has a depressed centre. 
During the next two days an areola forms about the vesicle extending 
from it a variable distance, usually one or two inches into the healthy 
skin. Its size depends upon the intensity of the infection. This areola 
is normally of a bright red colour and accompanied by some induration. 
It is generally at its height about the ninth day. The vesicle usually 
dries down to a firm, dark crust which remains from one to three 
weeks and falls off, leaving a bluish scar which fades to white, becoming 
somewhat honey-combed. When the process is at its height some consti- 
tutional disturbance is usually present ; there may be loss of appetite, 
fretfulness, and general indisposition, and the temperature is usually ele- 
vated from one to three degrees. The lymph nodes in the groin or axilla 
may be tender and swollen. These symptoms generally last for three or 
four days. 

If in a young infant the first inoculation is unsuccessful, at least 
three trials should be made with good virus, and in the event of further 
failure, after a year vaccination should be repeated. A failure to inocu- 
late does not mean insusceptibility to smallpox, as is often popularly be- 
lieved, but most frequently arises from the fact that the virus is inert. 
I have known one case in which the seventh, and another in which the 
thirteenth, inoculation was successful after previous failures: occasion- 
ally there are seen children who can not be inoculated at all. 

Constitutional symptoms, as previously stated, may he absent in very 
young infants; but in others there is quite constantly present a fever 
which runs a fairly regular course. It usually begins on the fourth or 
fifth day, is remittent in type, and rises gradually, reaching its high- 
est point with the full development of the vesicle. At this time oven 
without complications it may touch 104° or 105° F. The duration of the 
fever in cases running the usual course is four or five days. Accompany- 




MMMIHH 



Fig. 193. Fifth day. 




Fig. 194. Seventh day. 




Fig. 195. Ninth day. 





Fig. 196. Eleventh day. Fig. 197. Tenth day. 

Figs. 193 197. — Vaccine Vesicles. (Two-thirds natural size.) 
Figs. 193, 194, 195, and 190 show typical appearance of vesicle at the different stages when 

a very small scarification is made. 
Fig. 197 shows the effect of a larger scarification with a more intense areola. The amount 
of inflammation is excessive; hut not unusual. 
952 



VACCINIA. 



953 



ing the fever there may be anorexia, restlessness, loss of Bleep, slight in- 
digestion, and other symptoms of a genera] indisposition. 

Both the local and the general symptoms arc sometimes more severe. 
This may depend upon the susceptibility of the child, even though the 
lymph is pure and the vaccination properly done. The original vesicle 
may be much larger than usual, and small secondary vesicles may form 
in the neighbourhood. In very rare instances a generalised eruption of 
true vaccine vesicles occurs with fever and other general Bymptoms of cor- 
responding severity (Fig. 198). Single vesicles may be produced on dis- 
tant parts of the body as a result of auto-inoculation, usually by scratch- 
ing. Where eczema of the 
face is present, inoculation 
is not infrequently carried 
thither. Most of the very 
sore arms and legs, how- 
ever, are due to infection 
from pyogenic bacteria 
contained in the lymph, or 
to their accidental intro- 
duction at the time of vac- 
cination or subsequently. 
In the milder cases, the 
swelling and other evi- 
dences of local inflamma- 
tion are more marked than 
in a normal vaccination ; a 
drop or two of pus forms 
beneath the scab, and when the latter comes away an excavation is left 
which heals in two or three weeks. Or, the inflammation may extend 
more deeply into the connective tissue, to be followed by more extensive 
suppuration or sloughing, leaving an ugly ulcer an inch or more in 
diameter which slowly fills by granulation in from five to eight weeks. 
Sometimes the period of incubation is unduly prolonged, so that the 
vesicle does not form until the twelfth or fourteenth day, although its 
subsequent course may be normal. In other cases, the ineubat ion is shorter 
than usual, and the vesicle may appear as early as the third or fourth day. 

Much has been written about the so-called "raspberry excrescence" 
which not very infrequently takes the place of a proper vesicle. It is of 
a dark red colour, elevated, smooth or slightly granular, not sensitive, 
having no areola and no constitutional symptoms. It generally per- 
sists for two or three weeks, and slowly disappears, leaving no scar. It is 
usually the result of virus of feeble activity, and if it gives any protection 
it is very slight. Such cases should always he re-vaccinated, and in my 
experience re-vaccination is usually successful. 




Fig. 198. — Generalised Vaccinia. 
Boy eight years old. 



954 THE SPECIFIC INFECTIOUS DISEASES. 

Complications and Sequela.— Post-vaccine eruptions are many and 
of great variety. The most frequent is a general roseola, usually occur- 
ring at the height of the local process. Other eruptions seen are urti- 
caria, ami. rarely, purpura. Complications are chiefly from accidental 
infection. Syphilis and tuberculosis are excluded by the modern method 
of procuring the lymph. Tetanus can result only from carelessness 
or neglect of suitable precautions in preparing the lymph; proper 
legal restrictions regarding its production should make this impossible. 
The most common form of local infection is cellulitis, which may termi- 
nate in suppuration or sloughing at the site of vaccination, and some- 
times may cause suppuration of the neighbouring lymph nodes. Ery- 
sipelas may develop at any time before the skin is entirely healed ; it is 
usually due to neglect of proper precautions in the care of the vaccine sore. 

The mortality of vaccination is stated by Voigt, from careful statistics 
drawn from German sources, to have been 35 in 2,275,000 cases, including 
both primary and secondary vaccinations. Of the deaths, 19 were due to 
erysipelas, 8 to gangrene, 2 to cellulitis, 3 to "blood poisoning," and 3 to 
other causes. The occurrence of tetanus after vaccinia has already been 
mentioned. With proper precautions in preparing lymph it will not oc- 
cur. In fact, nearly all the deaths are from causes which are preventable. 

Treatment. — The whole purpose of treatment is to prevent infection. 
The first essentials are a clean limb, pure virus, and a sterile needle; the 
next, to allow thorough drying of the wound before the clothing touches 
it. After this nothing is necessary until the vesicle forms. Then the 
important thing is to prevent scratching and the irritation by the cloth- 
ing. All vaccine shields are objectionable. For an infant nothing is 
better than the sterilised gauze bandage, which can be kept in place by 
sewing to the stocking or sleeve of the shirt. Any constriction of the 
limb is injurious. For older children the simplest dressing is a pad of 
sterile gauze fastened to the limb by two pieces of adhesive plaster. 
Should the vesicle rupture and discharge serum, it should be kept clean 
and dry by dusting daily with boric acid. When the local symptoms are 
at all severe the limb should be kept at rest. An infected vaccination 
wound, like any other infected wound, requires careful surgical treat- 
ment; disastrous results often follow the use of poultices and other appli- 
cations much in vogue in domestic practice. 



CHAPTER VI. 

PERTUSSIS. 

( Whoojnng-Cough . ) 

Pertussis is a contagious disease which prevails epidemically and in 
most large cities endemically. Although it may affect persons of any 



PERTUSSIS. !);,;, 

age, it is generally seen in young children, and as a rule it occurs but 
once in the same individual. While in later childhood pertussis may be 
ranked as one of the milder infectious diseases, in inl'aii<\ n [a on,, of the 
most fatal. Its principal complications are broncho-pneumonia and con- 
vulsions. Pertussis is characterised by catarrhal and nervous symptoms. 
The catarrh affects the mucous membrane of the respiratory trad, and is 
probably due to a specific form of infection. It is accompanied by a 
hyperaesthetic condition of this mucous membrane. The most prominent 
nervous manifestation is a peculiar spasmodic cough which occurs in 
paroxysms, and from which the disease takes its name. The cough is no 
doubt of reflex origin, from an irritation which has been located by dif- 
ferent writers in various parts of the respiratory tract. In addition to 
these conditions, there is present in pertussis a marked irritability of the 
nervous system, which in infancy often shows itself by convulsions. 

Etiology. — Everything that is known of pertus>is suggests a micro- 
organism as its cause. Present evidence, moreover, points strongly to a 
bacillus first described by Bordet, although this lacks the final proof of 
the production of the disease by inoculation. Borders bacillus is a small 
(Irani-negative organism which in many points resembles the influenza 
bacillus. It is cultivated with difficulty, but grows best on potato-blood- 
agar. Subcultures do not require haemoglobin for their growth. It is 
difficult to obtain the organism from the respiratory secretion unless the 
plug of bronchial mucus brought up after a paroxysm of coughing is 
secured, as it develops chiefly deep in the respiratory tract. It is found 
only in the early stage of pertussis, rarely longer than a week after the 
whoop develops. The influenza bacillus is very frequently associated 
with it. 

Proximity to a patient seems all that is required to communicate the 
disease, and even close proximity is not necessary. There seems to be no 
doubt that the disease may be contracted in the open air. 

Predisposition. — Fully one-half the cases of pertussis occur during 
the first two years of life. The following are the statistics of Szabo 
(Buda-Pesth), showing the ages at which the disease was met with in 
4,591 cases, comprising the records of one clinic for thirty-four years: 

Under one year 1,028 cases. Three to four years 904 cases. 

One to two years 1,008 " Four to seven years 803 

Two to three years 659 " Over seven years 189 

Pertussis thus shows a stronger tendency to affect young infants than 
does any other contagious disease. A number of cases are on record in 
which it has occurred during the first month, and one has recently come 
to my notice where a child twelve days old was attacked, whose mother 
was suffering from the disease. The disease is nearly twice as frequent 
in the winter and spring as in the summer and autumn. Epidemics of 
pertussis often occur at the same time with or follow those of measles. 



956 THE SPECIFIC INFECTIOUS DISEASES. 

The susceptibility to pertussis is very great, and is equalled only by 
that to measles. Biederl reports that of lot children exposed during 
an epidemic in a certain village, 366, or ninety-one per cent, took the 
disease. 

Infective Period. — Pertussis may be communicated from the very be- 
ginning of the catarrhal stage; it is more contagious at this period than 
Later. There seems little doubt that it is contagious throughout the 
spasmodic stage and possibly longer. Quarantine is generally required 
for two months, and in many cases for a longer time. The usual source 
of the contagion is the patient, rarely the room or the clothing. While 
pertussis may be carried by a third person, this is very unlikely unless 
one has been in very close contact with the patient, and goes at once 
without change of clothing to another child. 

Incubation. — The very gradual onset of pertussis renders it impos- 
sible in the majority of cases to fix the exact date, and hence to estab- 
lish the definite duration of the period of incubation. In cases where 
this could best be determined it has usually been from seven to fourteen 
days, or about the same as in measles. If, after an exposure, sixteen 
days pass without the development of a cough, the probabilities are very 
strong that the disease has not been contracted. 

Lesions. — The only constant lesion of pertussis consists in a catarrhal 
inflammation of varying intensity, which affects the mucous membrane 
of the larynx, trachea, and bronchi, and sometimes that of the nose and 
pharynx. If the child dies during a paroxysm, either with or without 
convulsions, the brain is found intensely congested and may be the seat 
of punctate haemorrhages, or even larger extravasations. The lungs 
always show emphysema if the attack has been severe or protracted. 
The other pulmonary lesions are due to complications, the most fre- 
quent of which is broncho-pneumonia. Catarrhal enteritis and colitis 
are not infrequent. 

Symptoms. — The symptoms of pertussis are usually divided into three 
stages — the catarrhal, the spasmodic, and the stage of decline. 

Tlte catarrhal stage continues on the average for about ten days, 
although cases show considerable variation on this point. Some chil- 
dren whoop almost from the very beginning of the disease, while others 
may cough for three or four weeks before a typical whoop is noticed. 
The symptoms in the beginning are indistinguishable from those of an 
ordinary attack of subacute tracheo-bronchitis, and unless there has 
been an exposure to pertussis no suspicion is excited. After five or six 
days, however, the cough, instead of abating as in an ordinary cold, grad- 
ually increases in severity and occurs in paroxysms. At first these are 
mild, and there are only two or three a day, but they gradually increase 
in frequency and severity until the typical whoop is heard which marks 
the beginning of the spasmodic stage. During the first stage there may 



pertussis. 957 

• 

be symptoms of a mild grade of catarrhal inflammation of the note, 

pharynx, and larynx, and often there is a Blight elevation of temperature. 

The Spasmodic Stage. — In a typical paroxysm of average severity the 
child, who can usually foretell it, will often run for support to the lap 
of the mother or the nurse, or seize a chair with both hands. Then- 
now occurs a series of explosive coughs, from ten to twenty in number, 
coming in such rapid succession that the child can not get his breath 
between them; the face becomes of a deep red or purple colour, sometimes 
almost black; the veins of the face and scalp stand out prominently; 
the eyes are suffused, and seem almost to start from their sockets; there 
follows a long-drawn inspiration through the narrowed glottis, produc- 
ing the crowing sound known as the whoop; and then another succi 
of rapid coughs follows and another whoop. In a single severe paroxysm, 
which lasts two or three minutes, the child may whoop half a dozen 
times; with the final paroxysm a mass of tenacious mucus is usually 
brought up. In a young child vomiting is almost certain to follow, if 
food has been recently taken. Epistaxis sometimes occurs with nearly 
every severe paroxysm, but in most cases the bleeding is slight. After 
a severe attack the child is at times so exhausted as to be hardly able to 
stand. There is profuse perspiration; his mind is confused, and he may 
be completely dazed. In infants the attack may result in a degree of 
asphyxia requiring artificial respiration. Those old enough to describe 
their sensations tell of a sense of impending suffocation, the suffering 
from which is almost indescribable. 

The number of severe paroxysms or " kinks " in twenty-four hours 
varies, according to the severity of the case, from half a dozen to forty 
or fifty. There are always many more of a milder form. Paroxysms 
are often excited by eating or drinking anything cold, by a draught of 
air, or by imitation; they are usually more frequent during the night 
than the day, and in a close room than in the open air. 

In less severe cases no paroxysms of the grade above described may 
occur, and no typical whoop may be heard throughout the attack; but 
the paroxysmal nature of the cough which continues until the plug of 
mucus is expelled, the watery eyes, and the vomiting which follows a 
paroxysm, stamp the disease as pertussis. In young infants the whoop 
is frequently not marked. The child sometimes coughs until he is asphyx- 
iated, and yet no whoop occurs. The paroxysms are also modified by 
intercurrent disease, especially by attacks of pneumonia or severe bron- 
chitis. At such times they usually become less frequent and less typical, 
and may be absent for several days, returning as the complication sub- 
sides. 

The seat of the irritation which produces the cough has been vari- 
ously located by different observers. Some have thought it to he in the 
nose, others in the trachea, the bronchi, or the larynx. It is very prob- 



958 THE SPECIFIC INFECTIOUS DISEASES. 

able that it may not always be in the same place and that the infectious 
catarrh, which is really the most important element in the disease, may 
vary in its intensity and location in different rases. The weight of evi- 
dence seems to he that in the great majority of cases the source of irrita- 
tion is in the larynx or trachea. From laryngoscopic examinations made 
during the disease. Vol Ilerfi found the mucous membrane of the larynx 
to he swollen and congested, and occasionally the seat of small hemor- 
rhages or superficial ulcers. He states that the frequency and severity 
of the paroxysms corresponded with the degree of laryngitis, and he 
found that a paroxysm could always he excited by irritating the mucous 
membrane between the arytenoid cartilages. During a paroxysm he 
observed that there was a collection of mucus on the posterior laryngeal 
wall, the removal of which had the effect of shortening the paroxysm. 

Rossbach made laryngoscopic examinations, with negative results so 
far as the larynx was concerned, but he states that a plug of mucus could 
always be seen in the lower trachea for one or two minutes before the 
paroxysm occurred. There is little doubt that this collection of mucus 
is the exciting cause of the paroxysm, as it is a familiar clinical fact that 
the paroxysm continues until this is dislodged. 

The average duration of the spasmodic stage is about one month. 
It increases in intensity for the first two weeks, remains stationary for 
about a week, and then gradually diminishes in severity. The course and 
duration of this stage are, however, subject to wide variations. In mild 
cases it may last only a week; in severe cases, especially in the winter 
season, it may continue for three months, at times almost subsiding, but 
lighting up again with all its previous severity with every fresh attack 
of cold. After it has entirely ceased the whoop may return with an 
attack of bronchitis, and continue for a month or more. This is not to 
be regarded as a true relapse of pertussis. The habit of the paroxysmal 
cough once established, it tends to recur with every slight bronchitis, 
often for months afterward. 

The Stage of Decline. — Gradually the severity of the paroxysms abates, 
the whoop ceases, and the cough resembles more and more that of ordi- 
nary bronchitis. This stage usually continues about three weeks, but 
may be prolonged indefinitely in the winter months. 

Complications. — Hcemorrliages. — The haemorrhages of pertussis are 
mechanical, and depend upon the intense venous congestion which ac- 
companies the paroxysm. Epistaxis is the most frequent variety, and 
occurs in a considerable proportion of the severe cases, in a few with 
almost every severe paroxysm, but it is rarely severe enough to require 
local treatment. Haemorrhages from the mouth may have their origin 
either in the pharynx or the bronchi, the blood being brought up by the 
cough; such haemorrhages are usually small. Conjunctival haemorrhages 
are less frequent, and are usually slight, although I have seen the entire 



PERTUSSIS. 95Q 

conjunctiva covered. In a case under my observation there was bleeding 
from both ears with every Bevere paroxysm, for more than a week. This 
child had previously suffered from scarlatinal otitis, with perforation of 
the drum membrane. Small extravasations into the cellular tissue be- 
neath the eyes are occasionally seen, giving an appearance somewhat 
like an ordinary " black eve." Intracranial haemorrhages are not fre- 
quent, but many examples have been recorded, and they may be severe 
enough to produce death. They are usually meningeal, very rarely 
cerebral; according to their extent and location they may produce; 
hemiplegia, monoplegia, aphasia, facial paralysis, or disturb;) in 
sight, hearing, or sensation; in addition, there may be convulsions m- 
rigidity, but rarely complete coma. The extravasations are sometimes 
small and the symptoms which they produce may disappear at the end 
of a few w r eeks. More extensive haemorrhages may cause death. In 
almost every instance these haemorrhages have occurred as a direct result 
of the severe paroxysms. Purpura hemorrhagica is occasionally seen 
as a sequel of pertussis. 

Respiratory System. — The most serious complications of pertussis are 
connected with the lungs. By far the largest proportion of deaths is 
due to pulmonary complications, usually broncho-pneumonia. This is 
more frequent in winter and spring than in the summer months, and is 
especially to be dreaded during infancy. In later childhood lobar pneu- 
monia is occasionally seen. Pneumonia rarely begins before the second 
week of the disease, and most frequently develops at the height or toward 
the close of the spasmodic stage. The physical signs present no peculiar- 
ities; the cough changes somewhat in character during the pneumonia, 
and the wdioop may not be heard. The prognosis of the pneumonia is 
bad, because of the debilitated condition of the children at the time of 
its occurrence. A great danger is from the supervention of convulsions, 
this being a frequent mode of termination. As there is always consider- 
able emphysema the rapidity of breathing is frequently out of proportion 
to the temperature, wdiich often is only moderately elevated. If the child 
escapes the dangers of the acute stage, death may still occur from ex- 
haustion, owing to the protracted course which the disease frequently 
runs. 

Bronchitis of the large tubes is present in almost- all the severe cases, 
and is not of itself serious. Bronchitis of the small tubes has the same 
dangers and the same complications as broncho-pneumonia. 

Vesicular emphysema has been present, I think, in every ease which 
I have seen upon the post-mortem table; a certain amount of it, no 
doubt, occurs in every severe case. It is produced by the forcible cough 
of the paroxysm. In very severe cases interstitial emphysema is also 
found. Rupture of the air-blebs which form on the surface of the lung 
may lead to emphysema of the cellular tissue of the mediastinum, and 



960 THE SPECIFIC INFECTIOUS DISEASES. 

the air may find its way along the greal vessels into the neck, and finally 
into the Bubcutaneous cellular tissue of the entire body. Cases of general 
subcutaneous emphysema have beeu reported by Croker and by Hodge, 
botli of which ended fatally, one in three and one in eight days from 
the beginning of the emphysema. In the great majority of the cases 
vesicular emphysema is not permanent. 

Digestive System. — During the summer, infants with pertussis are 
almost certain to suffer from diarrhoea; it may be only an occasional 
symptom, or the attack may be severe and prolonged, resulting in the 
development of ileo-colitis. The intestinal complications may be almost 
as serious in summer as are those of the respiratory tract in winter. 
Vomiting is even more frequent than diarrhoea, and while it may be dis- 
tressing at any age, it is especially so in infancy. So frequently does the 
taking of food excite vomiting, that the nutrition of these patients often 
becomes a matter of the greatest difficulty, and in fact the most serious 
problem in the management of a case. Malnutrition and even marasmus 
may follow, or the general resistance of the child may become so reduced 
by lack of food that it falls a ready prey to pneumonia. 

Nervous System. — There may be convulsions, coma, paralysis, aphasia, 
disturbances of sight or hearing, and in rare cases even the mental con- 
dition may be affected. The most serious of these complications are 
convulsions. They are much more frequent in infancy than later, and 
particularly in those who are rachitic, in whom they are often fatal. Con- 
vulsions are of course more common in severe attacks, but they may occur 
suddenly where there has previously been no cause for anxiety. They 
are especially to be dreaded if pneumonia is present. The attack of con- 
vulsions may be the culmination of the extreme degree of nervous irri- 
tability which accompanies the paroxysm, it may be due to asphyxia, or 
to an intracranial lesion ; if the latter, there is usually meningeal haemor- 
rhage. This is to be suspected if there are continued convulsions for 
several hours, with general rigidity or hemiplegia. 

Disturbances of sight are not infrequent in severe cases; usually 
these are transient, but there may be blindness lasting two or three days 
or even weeks. The transient symptoms depend most likely upon cir- 
culatory changes that occur in the brain during the paroxysm, while 
those which last for two or three weeks are probably due to meningeal 
haemorrhage. Disturbances of hearing are rare. The different forms 
of paralysis occurring with pertussis may likewise be transient or per- 
manent. They are to be explained in the same way as the disturbances 
of the special senses. The most common form is hemiplegia. 

Albuminuria is not infrequent, being found in sixty-six of eighty- 
six examinations by Knight. The quantity of albumin is rarely large, 
and it may be accompanied by a few hyaline casts. Both are probably 
the result of cireulatory disturbances in the kidney. Other complica- 



PERTUSSIS. 961 

tions of pertussis are hernia, prolapsus ani, and ulcer of the frenum 
lingua 4 . 

Diagnosis. — The only constant features of pertussis are the court 
the disease and its communicability. In many cases the typical whoop 
is never heard. There are no symptoms by which a positive diagnosis 
can be made in the catarrhal stage; but a cough not accompanied by fever 
or physical signs, which steadily increases in severity for two weeks, 
in spite of treatment, and which occurs chiefly at night, is always Buspi- 
cious. When, in addition, the cough begins to come in paroxysms, ac- 
companied by suffusion of the face and occasionally by vomiting, there 
can be little doubt even though no whoop is heard. If the disease is 
prevalent the diagnosis is practically certain. Mild cases which do not 
go even as far as the symptoms mentioned are most puzzling. But if 
there is a history of exposure, if the cough continues from four to six 
weeks, little influenced by treatment, and if other cases follow, the dis- 
ease must be pertussis. Without evidence of communicability, however, 
one may be in doubt even after the disease is over. In early infancy 
any cough may have more or less of a spasmodic character, and a fairly 
typical whoop is often heard in the course of an ordinary bronchitis. 
I have several times seen abortive or very short attacks in one member 
of a family of children, the others having the disease in a typical form. 
Occurring by themselves such cases can not be recognised. 

Irritation of the pneumogastric or recurrent laryngeal nerve from 
enlarged tracheal or bronchial lymph nodes, whether of a simple or tuber- 
culous character, may give rise to a spasmodic cough, which in certain 
cases may be indistinguishable from pertussis. The prolonged duration 
of these cases is sometimes the only diagnostic point; but the paroxysms 
are usually not so severe as in true pertussis, and the course is generally 
less typical. 

The presence of a leucocytosis may be of considerable aid in diag- 
nosis. 1 

Prognosis. — The most important factor in the prognosis of the dis- 
ease is the age of the patient. After the fourth year it is indeed rare 
that either a fatal result or serious complications are seen ; but during 
infancy, and particularly during the first year, there are few diseases 
more to be dreaded. This is especially true on account of the connection 
of whooping-cough with the three most fatal conditions of infancy 

1 Frohlich and Meunier first called attention to the leucocytosis accompanying 
pertussis, far exceeding that of any other afebrile disease of the respiratory tract. It 
appears in the early part of the convulsive stage, and disappears slowly with improve- 
ment. The count is usually between 15,000 and 25,000, although it may reach 
50,000. There is an increase in the lymphocytes at the expense 1 of the ncutro- 
philes. The lymphocytes may form 60 to 80 per cent of the total leucocytes. The 
leucocytosis is little influenced by complications, and even during broncho-pneu- 
monia the lymphocytes continue to be in excess. 



962 THE SPECIFIC INFECTIOUS DISEASES. 

— broncho-pneumonia, diarrhoea] diseases, and convulsions. Fully two- 
thirds o( the deaths from whooping-cough occur during the first year of 
life. The prognosis is very much worse in infants under threa months 
than in those who are older and consequently have more resistance. It 
is better in the summer than in the winter, because broncho-pneumonia 
is then less frequent. It is particularly bad in delicate infants, in those 
who are rachitic, in those who are prone to attacks of bronchitis, in 
those who have suffered previously from pneumonia, and in those with 
a strong tendency to tuberculosis. 

The exact mortality of whooping-cough it is difficult to state in fig- 
ures. During the first year of life it is probably not far from twenty-five 
per cent, although it diminishes rapidly after this time. In foundling 
asylums and hospitals for infants it is to be ranked among the most 
fatal diseases, and in some epidemics the mortality in such institutions 
is as high as fifty per cent. 

Fully two-thirds of the deaths during whooping-cough are from 
broncho-pneumonia; the next most frequent cause is diarrhceal diseases. 
Convulsions may be the mode of death in either of the above conditions, 
or may occur apart from them. During the first year, death often results 
from marasmus, the child having been reduced by the prolonged disease. 
Occasionally death is due to asphyxia following a severe paroxysm, to 
intracranial haemorrhage, or to general emphysema. 

As a predisposing cause of tuberculosis, pertussis is second only to 
measles. In both diseases tuberculosis develops in much the same way 
and from practically the same causes. 

Prophylaxis. — Pertussis is a contagious disease, and a child suffering 
from it should be isolated from other children whenever this is possible. 
Children with pertussis should never be allowed to attend school, and 
needless exposure should always be avoided. 

Young infants, delicate children, and those with a predisposition to 
tuberculosis, should be most carefully protected against exposure, since 
it is in them chiefly that the disease is likely to be serious. As it is 
from the patient that the disease is nearly always contracted, there 
does not exist the same necessity for the fumigation and disinfection of 
apartments as after other contagious diseases. In institutions, however, 
this should always be practised, and in private houses if the room is 
subsequently to be occupied by an infant. 

It is as undesirable as it is impossible to confine a child with per- 
tussis to a single room during the attack; all those persons for whom 
exposure would be dangerous should therefore be sent away from the 
house. Quarantine should continue for at least six weeks, or until the 
spasmodic stage is over. 

Treatment. — We have as yet no specific remedy for pertussis. The 
important thing in most cases is the hygiene or general management of 



PERTUSSIS. 

the case; fully half of the eases seen in practice require nothing more. 
Much harm is done by indiscriminate drug giving. 

General Measures. — Fresh air is important throughout the attack. 
It is almost invariable that the paroxysms are fewer while patients are 
out of doors, and more frequent when they are in close rooms. Older 
children with pertussis may go out even in winter except on stormy, raw, 
or windy days. With infants and delicate children, the outdoor treatment 
in cold weather so enthusiastically advocated by some writers should be 
used with the greatest caution. It should certainly not be permitted 
if the patient has even the slightest amount of bronchitis. My own 
perience is that during the winter in a climate like that of New York 
or New England, the class of patients just referred to are better off 
indoors, taking their airing, if at all, in their rooms. In warm weather 
or in a mild climate all children should be kept in the open air as much 
as possible. 

A change of climate is desirable when the cough is unduly prolonged, 
also for delicate children in winter. A warm place at the seashore is 
one which is most likely to be beneficial. The improvement following a 
sea voyage is often very marked, surpassing even a residence at the sea- 
shore. 

The rooms occupied by children suffering from pertussis should be 
frequently changed, thoroughly aired, and occasionally fumigated. A 
change of rooms, clothing, bedding, etc., sometimes exerts a marked in- 
fluence on the course of very prolonged attacks, the inference being that 
continued re-infection takes place. Such a change should be made twice 
a week, and it is of special importance in hospitals, where many chil- 
dren quarantined in a ward seem to cough interminably. 

Careful feeding and attention to the bowels are matters of the great- 
est importance; with infants particularly, chronic indigestion and ab- 
dominal distention have a very marked effect in increasing the frequency 
of the paroxysms. The abdominal support furnished by a snugly fitting 
band, adds materially to the comfort of the patient in a severe attack. 
Feeding is difficult since vomiting occurs so easily. In most cases it is 
necessary to repeat the meal in a short time, if the first one has been 
vomited. Children over two years old should in all such cases be 
kept upon a fluid diet, chiefly of milk. For infants, milk should be 
diluted, and in many instances it should also be partially peptonised. 
Any medication which causes disturbance of the stomach should be 
omitted. 

Local applications to the rhino-pharynx or to the larynx may he made 
by means of a spray or swab. Eesorcin and carbolic acid, each in a one- 
per-cent solution, are most used. These applications are made once or 
twice daily. I have never seen from any of the above methods the ben- 
eficial results claimed, and I believe them to have been exaggerated. The 



964 THE SPECIFIC INFECTIOUS DISEASES. 

application of cocaine to the Larynx should never be employed in young 
children on account of the danger of poisoning. 

Inhalations arc o( much more value. They are useful to modify the 
catarrh by allaying irritation, facilitating the expulsion of the mucus, 
and possibly as antiseptics. Those most employed are carbolic acid, 
creosote, and cresolene. In my experience creosote is the best. These 
substances may be used upon cotton in a respirator, or vapourised over an 
alcohol lamp. The possibility of absorption should not be forgotten, 
and the urine should be watched. Where the paroxysms are frequent 
and of great severity, chloroform may be used to ward off convulsions 
or prevent dangerous asphyxia. In such conditions O'Dwyer used intu- 
bation with striking benefit. The tube entirely overcomes the glottic 
spasm which is the chief cause of suffering and danger. 

Internal Medication. — Of the innumerable drugs which have been 
recommended for this disease, there are two which possess undoubted 
advantages over all others, viz., belladonna and antipyrine. In giving 
belladonna it is important to begin with a small dose and gradually in- 
crease both its frequency and size until the physiological effects of the 
drug are produced. To an infant two years old, one-fourth of a minim 
of the fluid extract may be given every four hours as an initial dose, 
gradually increasing to every two hours; if atropine is used, gr. -^J-q 
may be given in the same way. Although belladonna usually has a de- 
cided influence in reducing both the frequency and the severity of the 
paroxysms, it causes many unpleasant symptoms, and its effects must 
be closely watched. 

Antipyrine has been in my experience more generally useful than 
any other single drug. It may be given with safety, even to young in- 
fants, in considerably larger doses than are ordinarily employed. For a 
child six months old the initial dose may be one grain every three hours ; 
later this may be given every two hours. For a child two years old the 
initial dose may be two grains repeated every four to six hours, grad- 
ually increasing up to two grains every two hours. Should pneumonia 
develop, the antipyrine should be discontinued. A combination of the 
bromide of sodium with antipyrine is often better than the latter given 
alone. 

Xearly all drugs which allay nervous irritability have a certain 
amount of effect in controlling the paroxysms of pertussis; codeine, 
chloral, and trional are useful where the night attacks are so severe as to 
prevent sleep. I do not believe that any form of internal medication 
or local treatment shortens pertussis; but, inasmuch as the disease is 
self-limited, great benefit to the patient results from the reduction of the 
number and the diminution of the severity of the paroxysms. 

In establishing the value of any method of treatment, it should be re- 
membered that the number of cases in which the duration of the -disease 



mumps. 965 

is short is large, and also that almosl any method of treatment if em- 
ployed after the attack has reached its height will be thought beneficial, 
as the natural tendency is then to improve. The value of any particular 

line of treatment is to be judged in a given case only by its effed in 
reducing the number and severity of the paroxysms. 'This oughl to be 
evident in the case of drugs within two or three days, and can only be 
determined by keeping a careful record of the number of Bevere parox- 
ysms day and night. Xo drug succeeds equally well in all Cases. 

In a mild case, where the numher of paroxysms does not <■ 
eight or ten during the day, where there is no vomiting and the genera] 
health is not affected, it is not usually advisable to continue the adminis- 
tration of any drugs throughout the disease. A single; dose of antipyrine 
or codeine at night may be all that is necessary. All cases in infants 
must be watched with great care and the parents warned of the possible 
dangers which may supervene suddenly, even in the course of mild 
attacks. For severe cases antipyrine should be given to diminish the 
frequency and the severity of the paroxysms, and inhalations of en 
used if much catarrh is present. All the fresh air possible should be 
allowed. For older children the same plan of treatment may be followed, 
or quinine or belladonna may be substituted for the antipyrine. 

As these drugs are given solely for the purpose of diminishing the 
frequency and severity of the paroxysms, their continuous use should 
be deferred until the symptoms are sufficiently severe to greatly disturb 
the child, the benefit at this period being more striking than if they are 
begun early and used continuously. 



CHAPTER VII. 

MUMPS. 

{Epidemic Parotitis.) 

Mumps is a contagious disease characterised by swelling of the par- 
otid, and sometimes of the other salivary glands, with constitutional 
symptoms which are usually mild. Both severe complications and a 
fatal termination are extremely infrequent. The disease is not a very 
common one, and general epidemics are rare. 

Pathology and Lesions. — The contagious character, definite incuba- 
tion, and typical course, stamp the disease as a general one due to a 
specific organism. This is probably a very minute Gram-negative diplo- 
coccus. It can be demonstrated in Steno's duct, in the testicles when 
epididymitis is present, and frequently in the blood. It is probable that 
infection takes place through the salivary ducts. 

The precise nature of the changes in the gland is still a matter of 



966 THE SPECIFIC INFECTIOUS DISEASES. 

dispute, as opportunities for pathological examination are very rare. 
From existing evidence it would appear thai the gland substance is first 
involved, and afterward the Burrounding connective tissue. The gland 
is the seat oi' an intense hyperaemia and oedema ; the walls of the salivary 
ducts are swollen, and the ducts are obstructed. While the primary dis- 
ease does not tend to excite suppuration, pyogenic germs may occasionally 
gain entrance and an abscess form; but this is to be regarded as a rare 
accidental infection. 

In the great proportion of cases the parotids alone are affected, al- 
though the same changes are occasionally found in the other salivary 
glands. There are no other essential lesions of the disease, those which 
are found depending upon complications. 

Etiology. — Mumps is spread by contagion, close contact being usually 
required to communicate the disease, although it is known to have been 
carried by a third person and even by clothing. The susceptibility of 
children to the poison of mumps is much less than is the case with the 
other contagious diseases, so that only a small number of those who are 
exposed take the disease. The greatest predisposition is between the 
fourth and fourteenth years. Infants are rarely affected, although a 
case in a child three weeks old is vouched for by so good an observer as 
Demme. 

Mumps is contagious from the beginning of the symptoms. Two 
cases have come under my notice in which the disease was communicated 
before any swelling was seen. It is impossible to fix with certainty the 
duration of the infective period. The disease is undoubtedly communi- 
cable for several days after the swelling has subsided; and for safety a 
case should be isolated for three weeks from the beginning of symptoms, 
or at least ten days after the swelling has disappeared. 

Incubation. — In forty-eight collected cases in which the incubation 
was definitely determined, it varied between three and twenty-five days. 
It was less than fourteen days in only four cases, and in twenty-six of 
the forty-eight cases it was between seventeen and twenty days. In three 
cases of my own in which it could be definitely fixed, the incubation was 
nineteen days in one case and twenty days in two cases. The average 
period of incubation, then, may be stated to be from seventeen to twenty 
days. 

Symptoms. — In the milder cases the local symptoms are the first to 
attract attention; in those which are more severe there are frequently 
prodromal symptoms of from twelve to forty-eight hours' duration — 
anorexia, headache, vomiting, pains in the back and limbs, and fever. 
Soltmann has reported a case ushered in by convulsions. The initial 
temperature in a mild attack is 100° to 101° F. ; in a severe one, from 
102° to 104° F. 

Of the local symptoms, the pain usually precedes the swelling; it is 



mumps. 967 

increased by movement of the jaws, by pressure, and sometimes by the 
presence of acid substances in the mouth. It is usually referred to the 
posterior part of the jaw just below the ear. The swelling may begin 
simultaneously in both parotids, but more frequently one side is involved 
a day or two in advance of the other. It usually reaches its maximum on 
the third day, often on the second, remains stationary for two or three 
days, and then subsides gradually. The degree of swelling varies with 
the severity of the attack. When it is marked, the patient may be so 
changed in appearance as scarcely to be recognisable; it fills the lateral 
region of the neck between the jaw and the sterno-mastoid muscle and 
extends forward upon the face to the zygomatic arch, so that the centre 
of the tumour is usually the lobe of the ear. The other salivary glands 
may swell simultaneously with the parotids, or several days later, even 
after the parotid tumour has disappeared. Occasionally swelling of the 
submaxillary or the sublingual glands occurs before that of the parotid, 
and in rare instances these may be the only glands affected. 

As a rule, the parotid of both sides is involved. Of 282 cases both 
sides were affected in 215. When one side alone is involved, it is the 
left a little more frequently than the right. The interval between the 
swelling of the two sides may be a week, or even five or six weeks, but 
usually it is only two or three days. 

The salivary secretion is usually very much diminished, and the dry 
mouth causes great discomfort. An exceptional instance has been re- 
ported by Simon, in which a distressing salivation occurred, the secre- 
tion amounting to six or eight ounces daily. 

Although as a rule the patient is not seriously ill, mumps may in 
rare cases produce most alarming and even dangerous symptoms. The 
temperature may for several days reach 104° F. or more, deglutition may 
be extremely difficult, pressure on the jugular veins may lead to venous 
hyperemia of the brain, causing headache and sometimes delirium ; there 
is sometimes great prostration and the symptoms of the typhoid condi- 
tion. These severe attacks are nearly always in children over twelve 
years old. 

The constitutional symptoms of mumps usually last from three to 
five days ; the swelling continues on an average a little less than a week. 
If the case has been a severe one, slight swelling may continue for two 
weeks or even longer. Eelapses, in which the opposite side from the one 
first affected is involved, are quite frequent, occurring in about ten per 
cent of the cases. 

Complications and Sequelae. — In childhood the complications are few 
and usually unimportant; but in adolescence they are occasionally seri- 
ous. Orchitis is exceedingly rare in childhood; of 230 cases observed 
by Eilliet and Barthez, this was seen in but ten, and only three of these 
cases were under fifteen years, and no case under twelve years old. When 



968 THE SPECIFIC INFECTIOUS DISEASES. 

orchitis occurs it is generally toward the end of the second or the begin- 
ning o( the third week; it is usually marked by an accession of fever, 
sometimes by a chill ; if severe, nervous symptoms may be present. The 
body of the testicle and not the epididymis is generally affected. The 
acute symptoms continue for three or four days, and the entire duration 
of the attack is about a week; although the testicle is often enlarged for 
some time afterward, and atrophy of the organ may follow. 

In females, congestion and swelling of the breasts, ovaries, or labia 
majora may occur; and, although these complications are all very rare, 
most of them have been observed even in young children. 

Nephritis has in a few instances followed mumps, sometimes coming 
on as late as four or five weeks after the attack. Single cases have been 
reported by Croner, Isham, Henoch, and others. Nervous sequelae are 
more frequent, but even these are rare. I have seen a case of multiple 
neuritis in a boy of twelve which developed two weeks after a severe at- 
tack of mumps. The paralysis was general, lasted for six weeks, and 
was followed by complete recovery. Jaffrey has reported a similar case. 
Facial paralysis three weeks after mumps has been reported by Hillier, 
apparently due to an extension of inflammation from the gland to the 
seventh nerve. 

Pearce.has collected an interesting series of forty cases of deafness 
following mumps, in which there was no sign of otitis, the symptoms 
coming on suddenly with vertigo, a staggering gait, and often with vomit- 
ing. In most of the cases the deafness was unilateral and the loss of 
hearing was permanent. The cause assigned was disease of the auditory 
nerve, the seat of the trouble being in the labyrinth. Toynbee has re- 
ported an instance of haemorrhage into the labyrinth. Otitis media is 
rarely seen. 

Suppuration of the parotid gland occurs in about one per cent of the 
cases, and is probably due to accidental infection. Gangrene and slough- 
ing of the parotid were observed twice by Demme in 117 cases; both of 
these proved fatal. Pneumonia, meningitis, endocarditis, and pericar- 
ditis have been observed as complications of mumps, although all are 
extremely rare. 

Prognosis. — In the great proportion of cases mumps is a mild dis- 
ease, and terminates in complete recovery in a few days. In young 
children complications are infrequent, and those which occur are rarely 
severe. 

Diagnosis. — Mumps is most likely to be confounded with acute swell- 
ing of the cervical lymph nodes. In a parotid swelling, the lobe of the 
ear is near the centre of the tumour, which extends backward to the 
sterno-mastoid muscle and forward upon the face as far as the zygomatic 
arch, embracing the angle and ramus of the jaw. 

A swollen lymph node is usually entirely below the ear and behind 



DIPHTHERIA. 969 

the jaw, not extending upon the face. The tumour is generally smaller 
and more circumscribed if only a single node is involved, and it comee 
on much more slowly than does mumps. When only the submaxillary 
or sublingual glands are affected, the diagnosis from swollen lymph nodes 
is sometimes impossible except by the course; of the disease. Mumps is 
characterised by the rapidity with which the swelling occurs, and by its 
relatively short duration. 

Treatment. — The disease is self-limited and the individual symptoms 
rarely distressing, so that in most cases very little treatment is required. 
If constitutional symptoms are present the patient should be kepi in 
bed, and if there are none he should be confined to the house. The gland 
should be protected by cotton or spongio-piline, and if the pain is severe 
heat should be applied. The diet should be liquid, on account of the 
pain produced by mastication. The mouth should be kept clean by the 
use of some antiseptic mouth-wash. The general symptoms and compli- 
cations are to be treated according to the indications presented. Cases 
of mumps occurring in schools or institutions should be quarantined for 
three weeks, and in private practice where there are susceptible persons. 
Fumigation and disinfection after an attack are unnecessary. 



CHAPTER VIII. 
DIPHTHERIA. 

Diphtheria may be defined as an acute, specific, communicable dis- 
ease due to the bacillus of Klebs and Loeffler. It is usually characterised 
by the formation of a false membrane upon certain mucous membranes, 
especially those of the tonsils, pharynx, nose, or larynx. Like other 
pathogenic organisms, however, this germ acts with varying intensity, 
and may cause inflammation of all degrees of severity, from a mild 
catarrhal angina to the most serious membranous inflammation; but 
to all alike the term diphtheria should be applied. In its mild form it 
may be almost without constitutional symptoms; but in its severe form 
it is attended by great general prostration, cardiac depression, and 
anaemia, it is frequently complicated by pneumonia and nephritis, and 
it may be followed by localised or general paralysis; it then constitutes 
one of the diseases most to be dreaded in childhood. 

Etiology. — The Bacillus DiphtliericB. — This was first described by 
Klebs in 1883, and during the following year it was isolated by Loeffler 
and shown to be pathogenic. It varies considerably in size and shape 
even in the same culture. In a specimen it occurs singly or in pairs, 
sometimes in chains of three or four; the bacilli may lie parallel, hut 
frequently two form an acute or an obtuse angle. They are straight or 



970 THE SPECIFIC INFECTIOUS DISEASES. 

slightly curved, and sometimes branching; they may be swollen or cluh- 
shaped at their ends. 

Distribution and Mode of Communication. — In most large cities diph- 
theria prevails endemic-ally, with periods in which outbreaks of consider- 
able severity are observed. In the country it prevails chiefly as an 
epidemic. The disease is often introduced into remote districts in some 
inexplicable manner, and before its nature is recognised a large number 
of persons may be exposed, and an epidemic results. 

Diphtheria does not arise de novo. Every case has its origin in a 
previous case either directly or remotely. The bacilli may enter the 
body through the inspired air; they may be taken into the mouth with 
toys or other articles upon w T hich they have lodged, or by kissing, and 
sometimes by accidental inoculation. As a rule, the bacilli first gain a 
foothold upon the mucous membrane of the tonsils, nose, or larynx. 

Direct infection is the cause in the great majority of the cases. There 
is no proof that the bacilli are contained in the breath of a person suf- 
fering from the disease. They are present in great numbers in the saliva 
and mucus from the mouth and nose, often being distributed by sneezing, 
coughing, or even by talking. They are contained in pieces of membrane 
which are discharged; they are not present in the urine or faeces. The 
most contagious cases are those of pharyngeal diphtheria on account of 
the amount of discharge which accompanies them. The least contagious 
are those in which the membrane is limited to the larynx and lower air 
passages. 

Direct infection may occur from persons convalescent from diph- 
theria, whose throats still contain virulent bacilli, or from persons suf- 
fering from a mild form of the disease, which is not recognised as diph- 
theria. In the latter way it is often spread in schools. It has been 
repeatedly shown that a person may harbour virulent bacilli in his nose or 
throat, and may even communicate the disease to others, without himself 
suffering from diphtheria at any time. 

The length of time during which a patient with diphtheria may con- 
vey the disease to others is somewhat uncertain. Transmission is possi- 
ble so long as virulent bacilli remain in the throat; these are frequently 
found two weeks after the membrane has disappeared and the patient is 
regarded as entirely well, and in a few cases they are found five or six 
weeks or longer after recovery. 

Indirect infection is not uncommon, and may occur from the bed or 
clothing of the patient, from the carpet, furniture, wall-paper or hang- 
ings of the room, from toys or picture-books, from dishes, feeding bottles, 
or drinking-cups, from swabs and brushes used for local applications 
to the throat, from spoons and tongue-depressors, and from surgical in- 
struments with which tracheotomy or intubation has been done. Diph- 
theria may be carried by a third person, but rarely except by one who 



DIPHTHERIA. <J71 

has been in close contact with the patient — either the physician or Dune. 
The frequency of diphtheria in physicians' families bears witness to the 
great danger of infection in this manner. 

Bacilli may retain their virulence for an indefinite period. Both 
Park and Loeffler found cultures in blood-serum to be virulent after ^'\('i\ 
months; Roux and Yersin, bacilli in dried membrane to be virulent after 
twenty weeks; and Abel, upon a child's toy after five months. 

Domestic animals may in rare instances be carriers of infection, and 
in the case of pigeons, at least, they may themselves suffer from the dis- 
ease. Diphtheria has been repeatedly spread by milk, but very rarely 
through the contamination of a water supply. 

Predisposing Causes. — Local conditions in the throat influence very 
largely the occurrence of diphtheria. An important predisposing cause 
is the existence of a chronic catarrhal inflammation of the mucous mem- 
branes of the nose and throat, so frequently found in children suffering 
from adenoid growths of the pharynx or from enlarged tonsils. These 
adenoid growths, the tonsillar crypts, and the cavities of carious teeth, 
may harbour the bacilli for a considerable time both before and after 
an attack. The condition of the mucous membranes of the nose and 
pharynx in other acute infectious diseases furnishes a marked predis- 
position to diphtheria. This is most striking in the case of measles 
and scarlet fever; it is seen less frequently in typhoid fever and 
influenza. 

The two sexes are about equally liable to the disease. Children 
under ten are much more often affected than those who are older, the 
greatest susceptibility as regards age being between the second and fifth 
years. 

While diphtheria is seen throughout the year, it is more frequent dur- 
ing the cold than the warm months. 

The incubation of diphtheria is short. In most of the cases in which 
it could be definitely traced it has been between two and five days. The 
virulence of the bacillus varies much in different cases and in different 
seasons, and while it is frequently true that persons infected from a mild 
type of the disease have a mild attack, and those infected from a ma- 
lignant one a severe attack, there is no certainty that such will be the 
sequence. Park states that, out of many hundreds tested in the laboratory 
of the New York Health Department, by far the most virulent bacillus 
was obtained from the throat of a boy who had what was clinically a very 
mild form of tonsillar diphtheria. 

The immunity conferred by one attack of diphtheria is not of long 
duration, amounting probably to a few months only; hut the passive 
immunity conferred by antitoxine is still shorter, lasting hut a Eew 
weeks. In patients therefore to whom antitoxine has been given, a B6C- 
ond attack may occur after a very brief time. 



972 



THE SPECIFIC INFECTIOUS DISEASES. 



Lesions. — The essential Lesions of diphtheria consist not in the pro- 
duction o\' a membrane, but, as long ago pointed out by Oertel, in cer- 
tain acute degenerative changes in the cells of the body caused by the 
diphtheria toxines. These changes are seen particularly in the epithelial 
cells of the affected mucous membranes, the heart muscle, the kidney, 
the liver, the central and peripheral nervous system, the spleen, and the 
lymph glands. There are other lesions which are the result of the action 
of other organisms, especially the streptococcus pyogenes and the pneu- 
mococcal, either alone, together, or in conjunction with the diphtheria 
bacillus. The most important lesions due to these organisms are broncho- 
pneumonia and nephritis; but there may be found in the blood, and in 
many of the organs of the body, the evidences of the invasion of these 
bacteria, i. e., a streptococcus septicaemia, less frequently a general pneu- 
mococcus infection. 

Distribution of the Diphtheria Bacillus in the Body. — Unlike many 
other pathogenic organisms, the diphtheria bacillus is not in most cases 
widely distributed throughout the body. It is found in great numbers 
on the surface of the affected mucous membranes and in the false mem- 
brane itself, particularly in its superficial portion, but it does not invade 
deeply the subjacent structures. 

The frequency with which the diphtheria bacillus and other organ- 
isms are found in the blood and viscera is shown in a series of 209 autop- 
sies studied by Councilman, Mallory, and Pearce, of Boston, in 1901. 
The following table shows the percentage of cases in which the different 
bacteria were found by culture : 



Diphtheria bacillus .... 

Streptococcus 

Staphylococcus aureus . 
Pneumococcus 



Heart's blood. 



6 per cent. 
20 
2.5 " 
1.5 " 



Liver. 



20 per cent. 
30 

4 

2.5 " 



Spleen. 



12 per cent. 
27 

3 

1.5 " 



Kidneys. 



19 per cent. 

28 
8 
5 



In this series, 153 cases were pure diphtheria; 56 were complicated 
by measles or scarlet fever or both. The streptococcus was much oftener 
found in the viscera in the complicated cases; otherwise there was little 
difference in the two groups of cases. 

The Diphtheria Toxines. — The wide-spread effects seen in diphtheria 
are due to the action of certain substances called toxines which the diph- 
theria bacillus produces during its growth on mucous membranes. They 
are very diffusible, readily entering the lymphatic circulation and the 
blood, and through these channels may affect the entire body. In 
susceptible animals there may be produced by the injection of these 
toxines all the characteristic lesions of diphtheria except the mem- 
brane, as well as the essential symptoms of the disease, even includ- 



PLATE XVIII. 








W&*$& 




The Diphtheritic Membrane. 

A. Typical tonsillar diphtheria. 

B. Severe pharyngeal diphtheria (fatal case). 

C. Pseudo-diphtheria. The specimen is seen from behind, the larynx and trachea 
having been laid open, and shows an extensive membrane involving the epiglottis and 
the entire lower pharynx, but extending into the larynx only a short distance. It is 

sen upon the posterior surface of the uvula and soft palate, the tonsils being only 
partially covered. The colour of the membrane is not characteristic of pseudo-diph- 
theria, as the same appearance is often seen in true diphtheria, particularly of the 
septic type. 



DIPHTHERIA. 973 

ing paralysis. For the production of the membrane Living bacilli are 
required. 

Catarrhal Diphtheria. — The routine practice of making cultures from 
diseased throats has established the fact that catarrhal inflammation may 
often be the only result of diphtheritic infection. Although to the naked 
eye there were only the ordinary changes of a simple inflammation, Oertel 
found the characteristic degenerative changes in the epithelial cells, vary- 
ing in degree with the severity of the process. 

The Diphtheritic Membrane. — The membrane in diphtheria is most 
frequently seen upon the mucous membrane of the tonsils, soft palate, 
uvula, pharynx, nose, larynx, trachea, and bronchi ; less frequently upon 
the mouth, lips, oesophagus, conjunctivae, middle ear, stomach, and genital 
organs. It may also affect fresh wounds, notably a tracheotomy wound, 
or any abraded cutaneous surface. The gross appearance of the mem- 
brane varies greatly (Plate XVIII). It is most frequently of a gray or 
mouse-colour, but it may be pearly white, yellow, green, and sometimes 
almost black. It is composed of fibrin, cells, granular matter, and bac- 
teria. Its consistency varies with the relative proportions of the differ- 
ent elements. When made up chiefly of fibrin it is firm and retains its 
form, often being discharged as a complete cast of the nose, larynx, or 
trachea. When the amount of fibrin is small the membrane is soft, 
friable, and sometimes granular. It is more closely adherent upon the 
mucous membranes covered with squamous epithelium, as in the pharynx 
and upper air passages, than upon those covered with columnar and 
ciliated epithelium, as in the lower air passages. 

The microscopical examination shows the fibrin to be sometimes 
granular, but usually in the form of a network, inclosing in its meshes 
small round cells and epithelial cells in various stages of degeneration. 
On the surface and in the superficial layer there is usually found quite a 
variety of bacteria including diphtheria bacilli. Beneath this is a cellu- 
lar layer containing little or no fibrin, in which also the diphtheria 
bacilli are usually found. In the deepest parts of the false membrane 
and in the mucous membrane itself the bacilli are few in number or 
absent. 

Changes which are similar in all the affected mucous membranes, are 
found in the epithelial cells which undergo marked degeneration with 
fragmentation of their nuclei; the mucosa is infiltrated with leucocytes. 
The infiltration with small round cells is variable in degree in the differ- 
ent mucous membranes; in some it extends deeply into the submucous 
and even the muscular layers, while in others it is very superficial. 
Marked evidences of degeneration are seen also in the cells infiltrating 
the deeper layers. In places the epithelium is detached, in others the 
line between the false membrane and the granular mucous membrane 
is scarcely distinguishable. 



974 THE SPECIFIC INFECTIOUS DISEASES. 

The Seat and the Distribution of the Membrane. — This varies some- 
what with the age of the patient, the season, and the peculiarity of the 
epidemic 

My own records show that the larynx is involved in about forty per 
cent of the cases in children under three years. In general the statement 
may be made that the younger the child the greater the liability of the 
disease to attack the larynx; also when the larynx is affected, the greater 
the tendency to spread to the trachea and bronchi. The larynx and 
lower air passages are rather more frequently attacked in winter than in 
summer. 

The tonsils are the most frequent and usually the earliest seat of the 
diphtheritic membrane; it may form here a tough, leathery patch, par- 
tially or completely covering and very adherent to them; or the disease 
may affect only the tonsillar crypts, so that the gross lesion may resem- 
ble that of ordinary follicular tonsillitis. There is in most cases only 
moderate swelling, but it may be so great that the tonsils are in contact. 
The surrounding cellular tissue is infiltrated with inflammatory products. 

The membrane covering the pharynx and uvula is also usually very 
adherent and intimately blended with the mucous membrane. The uvula 
is swollen and cedematous. Membrane may be seen only upon the fauces 
and uvula, or the posterior and lateral pharyngeal walls may be covered 
down to the level of the cricoid cartilage, but generally not below this 
point. If the posterior pharyngeal wall is covered, the membrane is apt 
to extend into the rhino-pharynx, and may fill the entire pharyngeal 
vault, covering the posterior portion of the velum and extending into 
the posterior nares. The adenoid tissue of the vault is frequently the 
part most affected. 

The nose may be involved secondarily to the rhino-pharynx, or the 
infection may be through the anterior nares ; if the latter, it is not infre- 
quently the only part involved. Many cases classed as nasal are really 
rhino-pharyngeal. The membrane in the pure nasal cases is usually 
thick and tough and often separates en masse. Both sides are generally 
involved, but it may be unilateral. 

The observations of Councilman, Mallory, and Pearce have shown 
that it is very common for the accessory sinuses of the nose, especially 
the antrum of Highmore, to be involved in fatal cases. It seems highly 
probable that infection of these parts explains the remarkable persistence 
of diphtheria bacilli in the nose which is occasionally seen. 

The epiglottis is swollen to three or four times its normal thickness, 
and the aryteno-epiglottic folds are oedematous. The anterior surface 
of the epiglottis is rarely covered by membrane; but its lateral borders 
and posterior surface, and the aryteno-epiglottic folds are involved in 
most of the severe pharyngeal cases (Plate XVIII, C). This lesion is 
associated with pharyngeal rather than with laryngeal diphtheria. 



DIPHTHERIA. 975 

The lesions which extend most deeply are thus seen in the tonsils, 
uvula, pharynx, and epiglottis. But even here there is very rarely deep 
or extensive sloughing. 

The lesions of the larynx, trachea, and bronchi arc similar to the 
above, although much more superficial. The interior of the larynx may 
be completely covered, the membrane coating the true and false 
cords and lining the ventricles of the larynx. The membrane in the 
larynx is not usually very adherent, and it frequently separates and is 
coughed up in large pieces or even as a cast. That covering the epiglot- 
tis and the aryteno-epiglottic folds is very adherent, like that in the 
pharynx. Catarrhal laryngitis is not an uncommon complication of 
pharyngeal diphtheria. 

In a considerable number of cases the membrane stops abruptly at 
the lower border of the larynx. In the trachea it is generally loosely 
attached, and often it is found at autopsy entirely separated from the 
mucous membrane. It is almost invariably associated with membrane in 
the larynx. Usually the membrane in the bronchi is continuous with 
that in the trachea. Occasionally I have seen the trachea and larger 
bronchi passed over and found membrane only in the larynx and smaller 
bronchi. As a rule, the bronchi of both sides are affected, and to the 
same degree. I once saw a case of laryngeal diphtheria in which mem- 
brane was found only in the bronchi of one lung. The above exceptions 
are to be explained as accidents in the mechanical transportation of 
bacilli. 

The extent of the membrane varies greatly in different cases. It 
may stop at the bifurcation of the trachea or at the bifurcation of the 
primary bronchi; but if it goes beyond this point it is likely to extend 
to the minutest subdivisions. Exceptionally a very tough fibrinous mem- 
brane forms in the trachea and bronchi, of sufficient thickness and con- 
sistency to be expelled as a cast, reproducing almost the entire bronchial 
tree. 

The inflammation of the mucous membrane of the larynx, trachea, 
and bronchi is very much less severe and more superficial in character 
than that of the pharynx, tonsils, and upper air passages. 

The buccal cavity is very seldom covered by the membrane; but in 
the worst cases of pharyngeal disease it may line the cheeks, cover the 
lips, gums, and more or less of the hard palate, but rarely the tongue. 
It usually occurs in patches rather than as a continuous membrane. In 
one case I saw the membrane on the lower lip, extending on to the face, 
though the buccal cavity was free. It is not common for the diphther- 
itic membrane to spread down the digestive tract. In 127 autopsies 
studied by Councilman, Mallory, and Pearce, in which the extent of the 
membrane was carefully noted, it was found twelve times in the oesoph- 
agus, five times in the stomach, and once in the duodenum. The 



976 THE SPECIFIC INFECTIOUS DISEASES. 

amount oi % membrane varied from small striatums on the folds of the 
stomach or oesophagus to a complete covering. The accompanying 
changes consist in infiltration, haemorrhage, and cell degeneration. In 
the intestines there is often found a hyperplasia of the lymphoid elements 
— solitary follicles and Peyer's patches — with changes similar to those 
in the lymph nodes elsewhere in the body, but nothing else that is char- 
acteristic. 

The writers just referred to found otitis, usually double, in sixty 
per cent of 144 autopsies ; although in less than one-third of the number 
was the complication recognised during life. Mastoid disease is infre- 
quent. Otitis is usually the result of direct extension from the pharynx. 
It may be due to the diphtheria bacillus alone, to the streptococcus alone, 
or to both combined ; occasionally the staphylococcus or pneumococcus is 
found. Conjunctival diphtheria is rare and probably due to accidental 
infection rather than extension through the lachrymal duct. Before the 
advent of antitoxine, it almost invariably resulted in destruction of the 
eye ; but a number of cases successfully treated have been reported. Diph- 
theria may attack any muco-cutaneous surface, especially the anus, pre- 
puce, or female genitals ; any abraded cutaneous surface, or recent wound, 
most frequently the tracheotomy wound of the neck. The diphtheria 
bacilli have been found in pure culture in superficial abscesses. 

Visceral Lesions. — The visceral lesions * of diphtheria are due partly 
to the action of the diphtheria toxines and partly to the invasion of the 
body with other organisms, especially the streptococcus. It is to experi- 
mental diphtheria that we owe our most accurate knowledge of the for- 
mer changes, for in human diphtheria the large proportion of all the 
fatal cases show infection with other organisms, particularly the strepto- 
coccus, to a less degree the pneumococcus or staphylococcus. The fre- 
quency with which these bacteria are found at autopsy in different organs 
has been already stated. 

The visceral lesions of diphtheria consist in wide-spread areas of cell 
degeneration similar to those which have already been described as occur- 
ring in the epithelial cells of the affected mucous membranes, together 
with haemorrhages due to changes in the blood-vessels and possibly in 
the blood itself. 

The lymph nodes of the cervical region are the most constantly and 
the most seriously affected. Similar but less marked changes are seen 
in the tracheo-bronchial and the mesenteric groups, and in the lymph 
nodules of the mucous membrane of the stomach and intestine. There 
are degenerative changes in the cells of the nodes most affected, with 
marked infiltration with leucocytes and frequently small haemorrhages. 

1 For an exhaustive study of the pathological anatomy of diphtheria, see mono- 
graph of Councilman, Mallory, and Pearce (Boston, 1901); being a study of 220 fatal 



DIPHTHERIA. 977 

The cellular tissue in the neighbourhood of the cervical Qod< 
extensively infiltrated with cells. The process in the lymph codes usu- 
ally terminates in resolution, rarely in Buppuration. 

The changes in the spleen arc quite constant. The organ is Bwollen, 

sometimes very much so, and deeply congested. Haemorrhages are often 
seen beneath the capsule; the spleen pulp is soft, the follicles are Large, 
and cell degeneration is quite constantly observed similar to that which 
takes place in the lymph nodes. 

There are frequently small haemorrhages beneath the capsule of the 
liver, and sometimes these are seen throughout the organ. There arc 
found scattered through the liver, areas of necrotic hepatic cell- which 
are peculiar to this disease; some of these areas are infiltrated with 
leucocytes. 

The kidneys are involved in almost all fatal cases except where death 
occurs early from laryngeal stenosis, also in nearly every severe case 
which terminates in recovery. Acute degeneration of the epithelium 
of the tubes and the tufts is seen in less severe cases and those of shorter 
duration, and is the direct result of the action of the toxines. In the 
more severe and protracted cases there is acute diffuse nephritis of vari- 
able type and intensity. There is no form of inflammation which is 
peculiar to diphtheria; in some cases the interstitial changes predominate 1 . 
in others the glomerular changes. Welch mentions hyaline changes in 
the glomerular capillaries and small arteries as the characteristic feature 
of the nephritis of diphtheria. 

In children dying suddenly in the early stage of the disease, cardiac 
thrombi are occasionally found. They may form rapidly only a short 
time before death, or slowly during several days when the circulation 
is very feeble. Portions of these thrombi may be carried into the pul- 
monary or systemic circulation, causing embolism in any of the arteries 
of the extremities, the lungs, or other viscera. Even in the early fatal 
cases the heart muscle may be seriously affected; in the later ones this 
is almost constant. The changes consist in a toxic myocarditis, the left 
ventricle being most involved. (See Myocarditis.) 

Degeneration of the arteries, especially of the endothelial layer, is 
occasionally seen, and there may be infiltration of the adventitia. The 
arteries of any of the viscera may be the seat of hyaline degeneration. 

Lesions of the brain are rare; both haemorrhage and embolism may 
be met with. In the spinal cord and membranes multiple haemorrhages 
occasionally occur. The characteristic lesion, however, consists in de- 
generative changes which are found to some degree in nearly all the more 
severe cases which have been examined. These affect the ganglion cells 
of the anterior horns, the anterior and posterior nerve-roots, and some- 
times the pyramidal tracts and columns of Goll. Some recent writers 
are of the opinion that the cord lesions are primary and the degenera- 
63 



978 THE SPECIFIC INFECTIOUS DISEASES. 

tioD of the spinal nerves secondary. However, the general opinion still 
prevails that certainly the less severe eases of diphtheritic paralysis are 
due to peripheral rather than to central lesions. Degenerative changes 
have been found also in the pneumogastric, spinal accessory, hypoglossal, 
motor-oculi. and in the cardiac nerves. These nerve degenerations pro- 
duced by the diphtheria toxine constitute one of the most striking lesions 
of diphtheria. (See Multiple Neuritis.) 

In infants and young children broncho-pneumonia is found at au- 
topsy in fully three-fourths of the cases, and in a large proportion of 
these it is the cause of death. It is well-nigh constant in cases of diph- 
theritic bronchitis of the finer tubes, and is usually present where the 
membrane has extended to the bifurcation of the trachea. The largest 
factor in the production of pneumonia is the aspiration of diphtheria 
bacilli and streptococci from the upper air passages; an important part 
is also played by the pneumococcus and the influenza bacillus. These 
organisms may be present in many combinations. 

With laryngeal stenosis, some emphysema is invariably present, and 
usually it is of the vesicular variety. In extreme or protracted cases of 
stenosis there may be interstitial emphysema. Eupture of some of these 
blebs may lead to the escape of air into the cellular tissue of the medi- 
astinum or of the neck, which may result in the production of a general 
emphysema of the subcutaneous cellular tissue. 

Blood. — According to the studies of Ewing, Billings, and others, 
there is found in all severe cases of diphtheria a reduction in the number 
of red cells to the extent of 500,000 to 2,000,000. There is a nearly 
proportionate reduction in the haemoglobin, this amounting to from 
twelve to twenty-eight per cent. While the haemoglobin falls coincidently 
with the number of red cells, it is regained much more slowly. Leucocy- 
tosis is generally present, and usually proportionate to the severity of 
the attack, but is occasionally wanting in the most severe as well as in 
some of the very mildest cases. The increase in the leucocytes is in the 
polymorphonuclear forms. Engel has noted the frequent presence of 
myelocytes, especially in fatal cases, the proportion of these in some in- 
stances reaching sixteen per cent of the white cells. In his observations, 
every case in which the myelocytes exceeded two per cent, proved fatal. 

Symptoms. — The clinical picture of diphtheria is one which presents 
wide variations, depending upon the principal location of the disease, its 
severity, and its complications. For practical purposes the following 
seems the simplest grouping that can be made: 

1. The mild cases, in which there is either no membrane, or the 
amount of membrane is small and limited to the tonsils or to the nose, 
with few or none of the constitutional symptoms which follow absorp- 
tion of the diphtheria poison. These cases partake essentially of the 
character of a local disease. 



DIPHTHERIA. <)?!) 

2. The severe cases in which there are marked evidences oi consti- 
tutional poisoning from diphtheria toxines. r rii is form is usually accom- 
panied by an extensive formation of membrane, in the pharynx and 

sometimes in the nose. 

3. The laryngeal cases in which the larynx may be primarily affected 

or in which it is involved secondarily to the severe pharyngeal form. 

4. The malignant cases. In these cases the symptoms of inflam- 
mation are especially prominent, not only in the pharynx but sometimes 
in the lymph glands and cellular tissue of the neck, which may be fol- 
lowed by suppuration or sloughing. This form is frequently complicated 
by broncho-pneumonia even without laryngeal disease, and sometimes by 
severe nephritis. 

Cases without Membrane. — During an epidemic of diphtheria in a 
family or an institution, cases are frequently seen which present the 
clinical evidences of only a catarrhal inflammation of the im 
pharynx, and yet cultures show the presence of the diphtheria bacillus. 
Such cases may be examples of simple catarrhal inflammation with 
the accidental presence of the diphtheria bacillus; or the inflamma- 
tion may be caused by infection with the diphtheria bacillus, hut not 
of sufficient intensity to lead to the production of a membrane. The 
latter is the view of pathologists, and the one to which clinicians 
must, it seems, inevitably come. However, a membrane has so long 
been regarded as a sine qua non of this disease that the existence of 
diphtheria without it, is something which the clinician finds it hard to 
grasp. 

Catarrhal diphtheria may be either pharyngeal or nasal. In the 
pharyngeal cases there are present the usual appearances belonging 1«» 
a catarrhal inflammation of moderate severity, often accompanied by 
swelling and tenderness of the cervical lymph glands. 

The nasal cases, in my experience, have been most frequent in in- 
fants or very young children. Constitutional symptoms may be wanting 
or so slight as to be overlooked. The only striking thing is a persistent 
nasal discharge which may be serous and frothy, purulent or bloody. It 
is usually copious, often excoriating the upper lip and sometimes con- 
tinuing for three or four weeks before any other symptoms are observed. 
I have known it to be mistaken for a syphilitic coryza. Such cases can 
be recognised with certainty only by cultures. Clinical evidence of their 
true character is sometimes afforded by the appearance of visible mem- 
brane in the nose or pharynx, by the development of croup, or by the 
fact that they cause diphtheria in other children. 

Catarrhal diphtheria is not in itself serious, but it may be followed, 
particularly in young children, by laryngeal diphtheria, or, after it has 
existed for a time, pharyngeal diphtheria may develop in its usual form. 
Cases like those just described are to be distinguished from others in 



980 THE SPECIFIC [NFECTIOUS DISEASES. 

which bacilli, either of the virulent or the aon-virulenl variety, are round 
without any evidence o\' inflammation. 

Cases with a Small Amount of Membrane. — 'Tonsillar Diphtheria. — 
The exudation is usually limited to the tonsils (Plate XVIII, A), and 

may partake of the character of either follicular or croupous tonsillitis; 
sometimes there is a slight extension to the faucial pillars or to the 
pharynx. These cases are quite common, and in some epidemics most 
of those seen are of this variety. They are more frequent in older chil- 
dren and adults than in infants and young children. 

The onset is accompanied hy a little soreness of the throat; the initial 
temperature is from 101° to 104° F. ; but the symptoms are often not 
severe enough to keep the patient in bed. If seen early, the throat shows 
slight redness, followed by a gray film, and later by a gray or white 
deposit upon the tonsils. It may start as a small patch which enlarges, 
or as small, isolated spots which coalesce or remain separate. Until it 
disappears the membrane generally remains of its original colour. It 
is generally quite adherent, and can not easily be removed with a swab; 
usually it is sharply defined, but Avith a somewhat irregular outline. In 
many cases the patch is not larger than the finger nail. The inflam- 
matory changes in the pharynx are slight ; a faint red areola is frequently 
present at the border of the patch. The lymph glands behind the jaw 
may be slightly swollen. There is no nasal discharge and very little 
increase in the saliva or mucus from the pharynx. Some constitutional 
symptoms are present, but they are never severe. The temperature com- 
monly continues above the normal while the membrane lasts, its usual 
range being from 100° to 102° F. The membrane remains from three 
to seven days — a shorter time if antitoxine is used. It is very often a 
matter of surprise that so small an exudate is so persistent, The urine 
is generally normal. The parents are loath to believe that strict quar- 
antine is necessary in so mild an illness; and when the membrane is 
only upon the tonsils, even after the disease has run its course, the 
physician may be led to doubt the diagnosis of diphtheria. 

In many cases one with experience can usually make an accurate diag- 
nosis from the clinical symptoms alone; but there are many others in 
which the diagnosis from ordinary tonsillitis is impossible, even by the 
most practised observers, except by cultures. When diphtheria bacilli 
are found in these mild cases the question often arises whether they 
may not be the non-virulent form. Park tested forty such cases, and 
found the bacilli to be virulent in thirty-five and non-virulent in five. 
In twenty of the forty cases the clinical diagnosis was follicular tonsillitis. 

Severe Cases. — The clinical picture of diphtheria is so modified by 
the use of antitoxine that those who see it given regularly and early can 
have but little conception of the horrors of this disease when not thus 
influenced. The onset in severe cases may be gradual, even insidious. 



DIPHTHERIA 

There is then a slight indisposition for a day or two, and perhaps 
soreness of the throat; the temperature may be bul little elevated, some- 
times less than 100° F. The symptoms may steadily increase in in- 
tensity for four or five days, until the maximum is reached. At other 
times the disease begins abruptly with vomiting, headache, chilly - 
tions, and a temperature of 103° or 101° F. Occasionally, the first thing 
to attract attention is the swelling of the cervical lymph glands, which 
may be so great that mumps is suspected. The abrupt onset is more often 
seen in young children than in those who are older. 

The membrane upon the tonsils resembles that of the mild form pre- 
viously described, but, instead of remaining limited to them, it gradually 
spreads to the fauces, the lateral wall of the pharynx, the uvula, the 
rhino-pharynx, and the posterior nares. The rapidity with which the 
membrane extends is in direct proportion to the severity of the attack. 
In some cases it may cover all the parts mentioned in twenty- four hours 
from its first appearance; in others this may require several days. When 
the nose is first affected there is an abundant discharge of serum and 
mucus, occasionally tinged with blood, which may continue some days 
before any membrane is visible. 

When a severe case is fully developed there is a very abundant dis- 
charge of mucus from the mouth and nose. The tonsils, the entire l'au- 
cial ring, and the pharynx are covered with membrane (Plate X V 1 1 1 . B) 
which is at first gray and gradually becomes darker, often being of a 
dirty olive-green colour. Membrane is sometimes seen upon the lips, or 
in patches in the mouth. There is obstruction to nasal respiration from 
the swelling of the palate, the tonsils, and the tissues of the rhino- 
pharynx; the mouth is half open, the breathing noisy, the tongue dry, 
and the lips are fissured and bleed readily. Occasionally large nasal 
haemorrhages occur which may necessitate plugging the nares. Both 
nostrils are generally blocked by the swelling and the false membrane ; 
the discharge excoriates the upper lip, and frequently has a foetid odour. 
During the second week there may be regurgitation of fluids through 
the nose, owing to paralysis of the palate. The lymph glands at the 
angle of the jaw swell rapidly; in severe cases they are very prominent, 
and there may also be extensive infiltration of the cellular tissue about 
them. 

The constitutional symptoms usually increase steadily with the ex- 
tension of the membrane. In the most severe cases the system is over- 
whelmed with the poison, and all the evidences of intense toxaemia are 
present by the third day of the disease. This is shown by great muscular 
weakness and prostration, by a feeble, rapid pulse, and a mental state 
of complete apathy or stupor, sometimes alternating with great restless- 
ness. It is more frequent for the constitutional symptoms to develop 
gradually, and not to reach their height before the fourth or fifth day. 



982 THE SPECIFIC INFECTIOUS DISEASES. 

The pulse becomes rapid, weak, ami compressible, sometimes irregular; 
and there is a great ami steadily increasing anaemia. The course of the 
temperature is irregular, and bears no constant relation to the severity 
of the other symptoms. Its usual range is from 101° to 103° F., but in 
some of the worst cases ii may never go above 101° F. It fluctuates 
irregularly with the development of complications, and sometimes with- 
out apparent cause. By the second or third day the urine regularly 
shows the presence of albumin, and by the end of the first week the quan- 
tity is often large. Granular and hyaline casts, and occasionally blood 
in small quantities, are also found. The amount of urine secreted is 
not noticeably diminished, and dropsy is rare. There is complete 
anorexia, and often vomiting and diarrhoea are present; in some of the 
cases they are prominent. Nervous symptoms are seen in all the very 
severe cases. There may be dulness and apatlry, but more frequently, 
owing to the discomfort arising from local symptoms, there is extreme 
restlessness and excitement, sometimes followed by delirium. 

At any time during the first week, but not often after that time, 
symptoms may arise indicating that the disease has extended to the 
larynx. The first signs of laryngeal invasion usually appear from the 
second to the fifth day of the disease. These are at first hoarseness, a 
croupy cough, and slight dyspnoea. In the severe cases these symptoms 
steadily increase until all the signs of laryngeal stenosis are present. 

The local process in the pharynx seems to be a self-limited one, even 
when no antitoxine is used. It usually reaches its height by the fifth or 
sixth day, and after that the appearances do not change materially for 
two or three days. From the seventh to the tenth day, in favourable 
cases, the diphtheritic membrane begins to loosen and separate from its 
attachment. It hangs loosely from the palate or uvula, and can often be 
pulled away in large masses. The detachment is frequently rapid, and 
in two or three days from the time when the first improvement is seen, 
the tonsils and pharynx may be almost free from membrane. The mu- 
cous surface left behind is of a bright-red colour and bleeds easily. The 
separation of the membrane in the nose and rhino-pharynx takes place 
more slowly. From the former it may disintegrate gradually or come 
away en masse. With the disappearance of the membrane the local symp- 
toms abate rapidly — the discharge ceases, the swelling of the lymph 
glands subsides, deglutition becomes easy and natural, and nasal breath- 
ing is re-established. When antitoxine is given the local process passes 
through similar stages, but much more rapidly. 

Simultaneously with these changes in the throat the constitutional 
symptoms improve, but much more slowly. Convalescence is often pro- 
tracted. The anaemia and muscular weakness, and most of all the feeble 
heart action may persist for weeks. 

Instead of the usual course just described, the diphtheritic mem- 



DIPHTHERIA. 083 

brane may persist for two or three weeks. In rare cases relapses occur, 
the membrane forming again after it has entirely or partially disappeared. 

The early course of the disease- in the fatal eases often doea not dif- 
fer from that of the severe eases which end in recovery, except in the 
malignant form, which kills in twenty-four or forty-eighi hours, and 
which is rare. In very young children death is most frequently dm.' 
to broncho-pneumonia, usually accompanying diphtheria of the larynx 
and bronchi. It may also be due to progrossixe asthenia the result of 
diphtheritic toxaemia, or to heart failure, which may come early or late; 
rarely it is due to nephritis. 

Laryngeal Diphtheria. — In cases of primary laryngeal diphtheria 
there are wanting most of the characteristic clinical features which dis- 
tinguish diphtheria of the pharynx. There are two reasons for this: 
one is the relatively rapid course of the disease, often producing death 
from local causes before the constitutional symptoms resulting from the 
absorption of the toxine have developed; the second reason is, that absorp- 
tion of the poison by the laryngeal mucous membrane is very feeble as 
compared with that which takes place from the pharynx. Hence it 
follows that glandular enlargements, albuminuria and asthenic symp- 
toms are generally wanting; also, that in the cases which come to autopsy 
early, the parenchymatous degenerations of the heart, kidney, and other 
organs are seldom found, but instead only such lesions as are connected 
with the laryngeal disease. The feeble contagion is due to the fact that 
the course is much shorter, and that the discharge from the nose and 
mouth is slight, or absent altogether. 

In its onset, diphtheria of the larynx is indistinguishable from 
catarrhal inflammation. It is usually somewhat less abrupt, and ap- 
parently not quite so severe for the first twelve hours or even for a longer 
time. There are present the same hoarse cough and voice, with slight 
stridor, gradually increasing. The constitutional symptoms arc usually 
not quite so marked, the temperature ranging from 99° to 101° F. The 
pulse is accelerated, but not weak or intermittent. It is the progp 
the disease which indicates its character, usually during the first twenty- 
four hours. A child beginning in the morning with such symptoms as 
have been described, may by evening show a decided change for the 
worse, or the symptoms may increase with great rapidity during the 
night. At first the voice is hoarse; later it is entirely lost. Dyspnoea 
in the beginning is scarcely noticeable, but steadily increases hour by 
hour. Sometimes from the first sign of hoarseness to such extreme 
dyspnoea as to necessitate intubation may he hut a few hours. During 
the second twenty-four hours all the symptoms are usually well developed. 
The respiration is often somewhat accelerated, hut it may he slower 
than normal. The face is pale and anxious. The ate nasi dilate with 
each inspiration. The loud, " sawing," stridulous breathing is pr 



984 THE SPECIFIC INFECTIOUS DISEASES. 

indicating obstruction both to inspiration and expiration. As the 
dyspnoea increases, all the accessory muscles of respiration are brought 
into action. There is now with every inspiration deep recession of the 

suprasternal fossa, the supraclavicular regions, and the epigastrium. The 
child tosses uneasily from side to side in his crib, at times struggling 
violently to get more air into the lungs. The pulse grows rapid and 
weaker. There is slight blueness of the finger nails and the lips; the 
face is usually pale; but later this too may be cyanotic. The skin is 
covered with clammy perspiration. On auscultating the chest, very rude 
respiratory sounds are heard, but no vesicular murmur. As the symp- 
toms increase in severity the temperature usually rises gradually, in some 
very severe cases at the rate of a degree an hour, until shortly before death 
it reaches 104° or even 106° F. Late in the disease the intellect becomes 
dull, the violent struggles for air cease, and the child passes into a con- 
dition of semi-stupor which gradually deepens until death occurs, which 
may be preceded by convulsions. 

Such is the usual course of the disease when unrelieved by treatment. 
Its progress is most rapid in infants, in whom death usually takes place 
in from thirty-six to forty-eight hours from the first symptoms. In older 
children the course is rather slower, and the attack may last from two 
days to a week, death occurring more frequently from bronchial croup or 
pneumonia. They are indicated by continued high temperature, rapid 
respiration, cyanosis, and increased prostration. 

The course of the disease is not always so regular. Occasionally for a 
week or more the symptoms are precisely like those of catarrhal laryngitis 
of moderate severity — hoarseness, laryngeal cough, little or no fever, and 
slight or occasional dyspnoea. Then there may be the sudden develop- 
ment of very severe symptoms, and death in a few hours. Great im- 
provement may follow the dislodgment of the membrane by vomiting or 
coughing, although in most cases it forms again. 

The issue of every case of diphtheritic laryngitis is doubtful. The 
prognosis is worse in infants and very young children than in those over 
three years of age. Before the days of antitoxine the mortality of cases 
not operated upon was from eighty to ninety per cent. Even with mod- 
ern methods of treatment the outlook in infants is bad; fully forty per 
cent die. 

It may be difficult in a given case to decide whether the dyspnoea is 
due to laryngeal inflammation, and whether this inflammation is catar- 
rhal or diphtheritic. The dyspnoea of retro-pharyngeal abscess, of for- 
eign bodies in the larynx or trachea, or of broncho-pneumonia, may be 
mistaken for that due to laryngitis. But in none of these conditions 
should there be any doubt if a careful examination is made and a history 
obtained. Eetro-pharyngeal abscess may be recognised by digital ex- 
amination of the pharynx ; broncho-pneumonia by the signs in the lungs, 



DIPHTHERIA. 

the difference in the character of the dyspnoea, and especially by the 
absence of the noisy stridor; in the ease of foreign bodies, whether they 
enter through the mouth or consist of ulcerating caseous glands which 
have ruptured into the trachea, the dyspnoea comes suddenly, and is not 
accompanied by fever. The main points by which catarrhal laryngitis 
is distinguished from the diphtheritic form have been considered under 
the former disease. In brief, diphtheritic inflammation may be assumed 
if there is severe, constant, and increasing dyspnoea with aphonia. 

Malignant Diphtheria. — The symptoms are usually severe from the 
outset. The exudation in these cases may be of a yellow, dirty-gray, 
or olive colour, sometimes being almost black from the presence of blood. 
The membrane is usually extensive, covering the entire pharynx, often 
extending to the nose and the middle ear, and occasionally spreading to 
the buccal cavity. There is great swelling of the tonsils and uvula, and 
it is often impossible to obtain a view of the pharynx. Sometimes the 
inflammation is of a necrotic character, and there may be extensive 
sloughing of the tonsils, the uvula, or the soft palate. The nasal discharge 
is generally abundant, and often very offensive. There is marked swelling 
of the cervical lymph glands, and frequently extensive infiltration of the 
cellular tissue of the neck, so that the head is thrown hack to relieve the 
pressure upon the larynx and trachea. The swelling sometimes forms 
a distinct collar, reaching from ear to ear and filling out the whole space 
beneath the jaw. The pressure upon the jugular veins leads to congestion 
and swelling of the face and congestion of the brain. 

The temperature is usually high; it follows no regular course, but 
generally fluctuates widely from 102° to 106° F. In some cases, how- 
ever, it may never be above 101° F. In the form characterised by very 
high temperature there is sometimes found a general streptococcus or 
pneumococcus infection, usually the former. The pulse is weak, rapid, 
and compressible. The peripheral circulation is poor, the extremities are 
often cold, there is extreme muscular prostration, and both vomiting and 
diarrhoea are frequent. There may be excitement, restlessness, and active 
delirium, or dulness, apathy, and stupor. Xephritis is very frequent and 
is often severe ; the urine contains a large amount of albumin and c. 
all varieties, but rarely blood. In a large proportion of the children under 
three years old broncho-pneumonia develops. Severe symptoms con- 
tinue for from two days to a week; the patient may die from the sud- 
den invasion of the larynx, or there may be suppression of urine and 
ura?mic convulsions ; but more frequently the cause of death is asthenia 
or broncho-pneumonia. Death usually occurs while the local disease is 
at its height. Occasionally it comes later from heart failure, after the 
signs of local improvement have begun. 

Those who manage to escape the dangers of the acute period have 
still others to encounter. Among the latter may be mentioned, ex- 



986 THE SPECIFIC INFECTIOUS DISEASES. 

tensive sloughing in the throat or of the cellular tissue of the neck, 
which may he followed by severe or even fatal haemorrhage, diffuse sup- 
puration of the same region, late nephritis, pneumonia, or pleurisy, and 
finally paralysis of the heart or respiration. 

Complications and Sequelae. — Most of the complications of diph- 
theria have already been mentioned either under the head of Lesions or 
Symptoms. It only remains to consider their clinical association. 

Otitis occurs particularly in the rhino-pharyngeal cases, and is some- 
times due to the diphtheria bacillus alone, but more often to mixed in- 
fection. The type of inflammation is often a severe one, and it may be 
accompanied by necrotic changes in the drum membrane which resem- 
ble those of scarlet fever. 

Broncho-pneumonia is the most frequent complication in young chil- 
dren. It occurs especially in laryngeal cases, and in those of a severe 
type whether the larynx is involved or not. Other pulmonary compli- 
cations are infrequent. Pleurisy with a serous effusion may occur in 
connection with severe nephritis, and empyema in septic cases. Emphy- 
sema is a complication of laryngeal diphtheria; it is nearly always 
vesicular, rarely interstitial. It may become general, extending into 
the cellular tissue of the neck and afterward that of the entire body. 
Pericarditis, endocarditis, and meningitis are all very rare and are seen 
chiefly in septic cases of the most severe type. Myocarditis is much 
more frequent, and is present to a greater or less degree in nearly all 
severe cases, although in but a small proportion of these does it give 
rise to distinct symptoms. It is closely connected pathologically with 
degeneration of the cardiac nerves, and it may be a cause of sudden 
death at any time during the acute period of the disease or during con- 
valescence. 

Thrombosis and embolism are among the less frequent complica- 
tions. If cerebral, they may cause hemiplegia, aphasia, and sometimes 
convulsions; if peripheral, they usually affect one of the lower extrem- 
ities, where they may cause sudden pain, numbness, and coldness of the 
limb, followed by partial paralysis, oedema, and sometimes even by gan- 
grene. Thrombosis of the pulmonary artery or of the heart may be a 
cause of sudden death; or this may occur more gradually with dyspnoea 
and praecordial distress, with pallor or cyanosis. Both thrombosis and 
embolism are associated with a very feeble action of the heart, and gen- 
erally they are preceded by degenerative changes in its muscular walls. 

Haemorrhages are usually nasal, and while in most cases they are not 
serious, they may necessitate plugging of the posterior nares. Bleeding 
from any other mucous membrane may occur, but it is rare except from 
the mouth. Subcutaneous haemorrhages are infrequent, and are evi- 
dence of a very high degree of diphtheritic toxaemia. They usually 
occur as small petechial spots, but are sometimes extensive. They may 



DIPHTHERIA. 987 

be seen upon almost any part of the body, most frequently upon the 
abdomen and lower extremities; but the most, extensive extravasation 
I have ever seen was in the neck, reaching from the clavicle almost 
to the ear and covering nearly one lateral half of the neck. 

Albumin is present in the urine of almost every case of moderate 
severity, usually depending upon acute degeneration of the kidneys. 
Acute nephritis is most frequently seen in severe cases. It then usually 
develops at the height of the local disease, but may come during con- 
valescence. Albumin and casts are found in the urine, but rarely is 
there dropsy or signs of uraemia. Less frequently a more severe form 
of inflammation occurs, with dropsy, scanty urine, or even suppression, 
vomiting, and all the usual symptoms of acute uraemia. This complica- 
tion may be a cause of death. 

Functional disturbances of the stomach are present in most of the 
severe cases, but lesions of the mucous membrane are rare. While diar- 
rhoea is often seen without intestinal lesions, the latter are of frequent 
occurrence. The most characteristic form of inflammation is a follicular 
ileo-colitis, which, however, seldom goes on to ulceration. It is ex- 
tremely rare that the membranous form is seen, and then it is almost 
always associated with the presence of other organisms than the diph- 
theria bacillus. 

Diphtheria is usually followed by a severe and often persistent anae- 
mia which may continue for weeks. Pneumonia, nephritis, and cardiac 
disease may first show themselves during convalescence, and so be ranked 
as sequelae. The most important sequel of diphtheria, however, is post- 
diphtheritic paralysis, already discussed in the chapter on Multiple 
Neuritis. 

Pneumo gastric Paralysis. — Some cases of diphtheria, especially those 
which receive no antitoxine or when the antitoxine is administered late or 
in too small amount, present a group of symptoms which have been 
referred to degeneration of the pneumogastric nerves. The evidence, 
however, is by no means conclusive that this is the true explanation of 
the clinical picture, which is a familiar one. 

These symptoms may come on at any time in the course of the dis- 
ease, but seldom earlier than the end of the second week. By this 
time the throat has usually cleared off entirely, and the patient is con- 
sidered convalescent. The symptoms relate to the stomach, the heart, 
and the respiration. Usually the first thing to attract notice is that the 
patient refuses food and vomits occasionally, afterward persistently, 
without apparent cause. If the pulse is carefully observed it is found 
to be much slower than previously, being only 80 or 90 when it was 
formerly 120 or more. It is also weaker, compressible, and often some- 
what irregular. The face is pale or slightly cyanotic, and moderate 
dyspnoea may be noticed. There are frequent attacks of severe abdom- 



OSS THE SPECIFIC INFECTIOUS DISEASES. 

inal pain which comes in paroxysms, and is usually referred to the 
epigastrium. These symptoms in most cases gradually increase in sever- 
ity for two or throe days, but sometimes develop with such intensity thai 
death occurs within twelve or twenty-four hours. The later symptoms 
are a continuance of the abdominal pain and vomiting; there is a feel- 
ing of groat precordial oppression and distress accompanied by dysp- 
noea ; the respiration is shallow and often rapid ; the face is either pale 
or cyanotic; the extremities, cold; the pulse, slow, irregular, and inter- 
mittent, becoming rapid on the slightest exertion. The heart sounds 
are weak, the muscular quality is absent, and the rhythm much disturbed. 
There may be no murmurs. There is great restlessness, but the mind 
is entirely clear. Death usually results from heart failure, which may 
come quite suddenly, often from so slight exertion as turning over in 
bed or attempting to take food. 

Xot all the cases are so severe. In the milder forms there is some 
palpitation, an irregular pulse, slight dyspnoea, and occasional syncopal 
attacks, but of no great severity. Such symptoms may come and go 
for several days and then disappear; but more frequently they prove to 
be the beginning of the more serious form of the complication. The 
time of occurrence of these symptoms varies considerably. It may be 
as late as the third or fourth week. The late cases are generally 
associated with some other form of post-diphtheritic paralysis. 

Sudden heart failure may be seen late in diphtheria quite apart from 
the symptoms just described. It may occur with few or no premonitory 
symptoms; as when a child falls dead after walking across a room, or 
suddenly sitting up in bed, or from some other muscular effort, or pos- 
sibly as a consequence of passion or excitement. I knew of one little 
girl who was considered well enough to go coasting and who died sud- 
denly after the effort. 

The explanation of heart failure during or after diphtheria is there- 
fore not always the same. When it occurs at the height of the disease 
it is sometimes due to cardiac thrombosis, probably always associated 
with changes in the muscular walls. When it occurs late and follows 
some sudden muscular effort or excitement without premonitory symp- 
toms of any sort, it is probably the result of changes in the muscular 
walls — a toxic myocarditis. 

Diagnosis. — The diagnosis of diphtheria rests upon two kinds of evi- 
dence — clinical and bacteriological. In mild cases and in the early stage 
only bacteriological evidence can be relied upon. However, the clinical 
manifestations of the disease are important and should not be ignored. 
It is in most cases possible to say from clinical symptoms that a case 
is one of diphtheria ; but it is never possible to say from symptoms alone 
that a case is not diphtheria. Cultures, therefore, are of the greatest 
assistance, and should if possible be made in every case. They are ncc- 



DIPHTHERIA. 

essary in the mild cases in order thai a correcl diagnosis nun be made 
and proper quarantine regulations enforced; otherwise a case might be 

dismissed as simple tonsillitis and no precautions taken. 

The mere presence of diphtheria bacilli in the throat does not p 
that a person has diphtheria any more than the presence of the pneumo- 

COCCUS in his saliva proves that he has pneumonia; hut when diphtheria 
bacilli are associated with clinical evidences of inflammation of the 
throat or nose the diagnosis may he regarded as established. Again, the 
case may be one of diphtheria and the bacilli not found at the first 
examination, although found subsequently. In using antitoxine one 
must, in perhaps the majority of cases, be guided by clinical symptoms 
alone, not waiting for the result of the bacteriological examination. It 
is therefore important that both methods of diagnosis should be em- 
ployed. 

1. The Clinical DiaCxXOSIS. — Not much importance can be attached 
to the mode of onset; for diphtheria may begin in many different ways. 
The presence of a nasal discharge, especially if abundant, ichorous 
and tinged with blood, the early development of the symptoms of croup, 
the rapid enlargement of the cervical lymph glands, and the early ap- 
pearance of albumin in the urine — all point strongly to diphtheria. 
Later symptoms which are especially diagnostic are marked anaemia, 
progressive asthenia, intense toxaemia often with a low temperature, very 
feeble pulse which is sometimes slow, sometimes rapid, sudden attacks 
of syncope, nasal haemorrhages, nasal regurgitation from paralysis of 
the soft palate, contagion, and, finally, the development of paralysis of 
the muscles of the throat, eye, or extremities, with paralysis of the heart 
or respiration. 

The membrane of diphtheria generally appears first upon the tonsils, 
usually as a gray film which gradually becomes more dense and white, 
and often has the look of being plastered on. The colour of older mem- 
brane is gray, greenish-yellow, brown, sometimes black. Beginning as 
a small patch, it soon covers the tonsils. It frequently affects one tonsil 
twenty-four or thirty-six hours before the other, and occasionally it is 
confined to one side. In exceptional cases it begins in the crypts of the 
tonsil and appears as isolated dots, which may coalesce to form a con- 
tinuous patch like that already described, or it may remain isolated like 
the exudate of an ordinary follicular tonsillitis. More important is 
the fact that the membrane spreads from the original seat, and also the 
manner of its spreading. If it extends beyond the tonsils to the walls 
of the pharynx, the faucial pillars, and the uvula, it is almost surely 
diphtheria. The same is true of doubtful patches on the tonsils or fauces 
followed by symptoms of croup. The rapidity of the spreading varies 
much in the different cases, depending upon the intensity of the infec- 
tion; but the gradual extension, as shown by observations made at in- 



900 THE SPECIFIC INFECTIOUS DISEASES. 

tervala of six or eight hours, usually settles the diagnosis in the primary 
cases. Bowever, it' the throat Bymptoms complicate measles or scarlet 
fever the above rules do not apply. Most of the membranous inflam- 
mations o( the throat seen in these diseases are not due to diphtheria. 
This is particularly true of those which occur at the height of the pri- 
mary disease. Those which develop at a later period are often due to 
diphtheria. 

Primary membranous inflammation of the larynx may always be 
safely regarded as diphtheria ; but if there is no visible membrane, the 
diagnosis is rendered positive only by a bacteriological examination. 
This may be true of many nasal cases where the only symptoms are a 
discharge of the character previously described. Such cases may con- 
tinue for weeks with no symptoms other than the discharge, especially 
in infants. 

It is seldom difficult to distinguish diphtheria from any other dis- 
ease; but the exudation upon the pharynx or tonsils may be confounded 
with thrush or ulcero-membranous angina. The appearance of the ton- 
sils on the second or third day after tonsillotomy has been performed, 
may easily be mistaken for diphtheria by one who is unfamiliar with the 
appearance of the post-operative wound. 

Diphtheria of the mouth may be mistaken for herpetic or ulcerative 
stomatitis ; but, as a rule, it is seen only in the worst cases of pharyngeal 
diphtheria. Diphtheria of the mouth alone is so rare that it may be 
ignored. 

It is sometimes difficult to distinguish cases of scarlet fever in which 
the throat symptoms are severe and appear early, from cases of primary 
diphtheria. In many of these cases the eruption appears late, and is 
not characteristic. Much importance is to be attached, as pointing 
toward scarlet fever, to a prevailing epidemic, a history of exposure, a 
sudden onset with severe symptoms, vomiting, prostration, very high 
temperature, and to a very active inflammation in the pharynx. In all 
cases with a sudden onset, in which from the throat symptoms one is 
inclined to make a diagnosis of diphtheria, the possibility of scarlet 
fever should not be forgotten, and one should never omit to examine 
the patient thoroughly for an eruption. 

2. The Bacteriological Diagnosis. — The Technique. — In many 
cases an immediate diagnosis may be reached by the examination of a 
cover-glass smear from the throat. This method, although often valu- 
able, is not adapted for general use, as bacilli directly from the throat 
are much less typical than those from cultures, and the chances of con- 
tamination are much increased. Furthermore, the mouth often contains 
other bacilli which somewhat resemble the diphtheria bacillus. 

In taking a culture from the throat, the tongue should be depressed 
and the tonsils, pharynx, or other seat of visible membrane rubbed firmly 



DIPHTHERIA. 99] 

with a swab, which is then rubbed over the surface of the culture-medium 
in the tube or on the plate, in laryngeal cases the culture should be 
taken from the posterior wall of the pharynx, and in nasal cases from 
the nostril. The tube or plate is then placed in an incubator for eight 
to twelve hours, at the end of which lime the colonies may be examined. 
Examination, in the great majority of cases, sbows either a great num- 
ber of diphtheria bacilli and a few cocci, or only cocci in pairs or short 
chains; exceptionally, the cocci and bacilli may be present in nearly equal 
numbers. A definite opinion should not be given wit bout examining 
several colonies. 

The Reliance to he Placed upon Bacteriological Diagnosis. — The diph- 
theria bacillus will almost invariably be found, if there is visible mem- 
brane in the pharynx, if no antiseptics have been applied shortly before 
using the swab, and if the culture has been made with sufficient care to 
avoid contamination. 

The diphtheria bacillus sometimes disappears early; hence cultures 
made while the membrane is loosening may be negative. If the mem- 
brane has disappeared, or if none has been present, it is not infrequently 
necessary to go into the tonsillar crypts with a probe or spoon to dis- 
cover bacilli. It is therefore important in all cases to consider the dura- 
tion of the disease before drawing a conclusion from a negative culture. 
If the case is one of laryngeal disease without pharyngeal exudation, 
an early culture is negative in nearly half the cases; although a little 
later bacilli may be coughed up and found in the pharynx in abundance. 
A single negative culture should never be taken as conclusive. 

For diagnostic purposes, all bacilli present in suspicious throats, hav- 
ing the morphological and cultural characteristics of diphtheria bacilli, 
are to be regarded as virulent. 

Non-virulent Bacilli Resembling the Diphtheria Bacillus. — There 
may be found in throats a form which corresponds in every other charac- 
teristic with the diphtheria bacillus, but which lacks virulence, as shown 
by animal tests. Also, another form, which, though in many particulars 
resembling the diphtheria bacillus, differs from it in being shorter, 
plumper, and more uniform in size, and in producing an alkali in broth 
cultures; to this the term pseudo-diphtheria bacillus has been given. It 
is more frequently seen than the form just described and like it is non- 
virulent. Both these forms are rare in throats where a suspicion of diph- 
theria exists. 

The Presence of Virulent Bacilli in the Throats of Healthy Persons. 
— That virulent bacilli may be harboured for an indefinite period in the 
throat or nose of a healthy person is proved by many observations. The 
New York Health Department made observations upon forty-eight chil- 
dren in fourteen families in which one or more cases of diphtheria bad 
occurred, and where no attempt at isolation had been made. In one- 



002 THE SPECIFIC INFECTIOUS DISEASES. 

half these cases bacilli wore found, and animal tests showed them to be 
virulent in every one of six cases tested, although four of the children 
did not develop diphtheria. Of the entire number, forty per cent subse- 
quently developed diphtheria. My own experience in two institutions 
where diphtheria has been endemic, fully confirms the observation that 
bacilli of all degrees of virulence are very frequently found in the noses 
or throats of such exposed children, although a large proportion of them 
never develop the disease. Outside of institutions and infected tene- 
ment houses, however, such a condition is extremely rare. 

Prognosis. — Many possibilities exist, and even the mildest case must 
be regarded as serious and carefully watched, since one can never know 
when unfavourable symptoms may develop. 

The factors to be considered in the prognosis of any given case are: 
the age and previous condition of the patient; the extent of the mem- 
brane and the rapidity w T ith which it is spreading; the degree of diph- 
theritic toxaemia as shown by the condition of the pulse and the nervous 
symptoms; whether or not the membrane has invaded the larynx; and 
the presence or absence of complications, especially nephritis and bron- 
cho-pneumonia; but of more importance than any or all these things is 
whether antitoxine is used and when it is administered. 

The following figures are from the Eeport of the Health Depart- 
ment of Chicago of cases treated from October 5, 1895, to February 28, 
1899: 

Died. Mortality. 

Injected 1st day 355 1 0.27 per cent. 

2d day 1,018 17 1.67 

3d day 1,509 57 3.77 

4th day 720 82 11.39 

later 469 119 25.37 



Totals 4,071 276 6.77 

In all these cases the diagnosis of diphtheria was confirmed by 
cultures. 

Diphtheria mortality is highest during the first two years of life, 
from its strong tendency to invade the larynx and lower air passages, 
and from the frequency with which broncho-pneumonia occurs as a com- 
plication. Those whose experience with this disease does not antedate 
the introduction of antitoxine can scarcely appreciate the results previ- 
ously obtained. Of eighty-five consecutive cases under twenty-six 
months of age observed in the New York Infant Asylum, in a period 
extending over two years, the mortality was sixty-eight per cent; in over 
two-thirds of the fatal cases the disease involved the larynx. In diph- 
theria hospitals, where most of the mild cases included in the above 
statistics would probably not have been admitted, the mortality in 
children under two years formerly varied from sixty to eighty per 



DIPHTHERIA. \)<x> 

cent; in private practice it ranged for this age from thirty to 
per cent. 

It can not be too often emphasised thai the danger from diphtheria 

is not over when the throat has cleared. The most frequent can 
death after this time are broncho-pneumonia and cardiac para] 

Prophylaxis. — In no infectious disease, smallpox alone excepted, can 
so much be accomplished in the way of prevention as in diphtheria. 

Public funerals of children dying from diphtheria should invariably 
be prohibited. Schools should be closed whenever the disease is epi- 
demic. Children from families where diphtheria exists should not be 
allowed to attend school, nor mingle in any way with other children, 
for the reasons that they may, while healthy, be the carriers of the dis- 
ease; and, what is even more important, that they may be themselves 
suffering from diphtheria in an early stage or in a mild form. 

In every large city, hospitals for diphtheria patients should be estab- 
lished, not only for the poor, but with private rooms for cases develop- 
ing in hotels or other places where isolation is impossible. Every city 
should be provided with a steam disinfecting plant, where carpets, blan- 
kets, bedding, etc., can be sent from the sick-room for disinfection. 

Quarantine. — Not only every undoubted case of diphtheria, but every 
suspected case, should be immediately isolated. Quarantine for the lat- 
ter should continue until the diagnosis is settled either by a bacterio- 
logical examination or by the course of the disease. Positive and sus- 
pected cases should not be isolated together. The quarantine in every 
instance must be complete. If possible, cultures should be taken from 
the throats of all exposed children. Those containing diphtheria bacilli 
should be quarantined like cases of diphtheria, for they may be equally 
dangerous ; they should use gargles and sprays, and the nose and throat 
should be closely watched. 

Bacteriology has furnished some very definite data from which the 
necessary duration of the period of quarantine may be determined. In 
this the physician is to be guided by the time that the bacilli remain in 
the throat, for the patient is to be considered as dangerous while they 
persist. This point was investigated by the New York Health Depart- 
ment in 605 cases: In 304 of these the bacilli had disappeared by the 
third day after the membrane was gone; and in 301 they persisted for a 
longer time — in 176, for seven days; in 64, for twelve days; in 36, for 
fifteen days; in 12, for twenty-one days; in 4, for twenty-eight days : in 
4, for thirty-five days; and in 2, for sixty-three days. Many of the cases 
in which the bacilli have persisted for an unusual time have been those 
of nasal diphtheria; in some of these it is doubtless owing to the fact 
that the nasal sinuses, especially the antrum, have been invaded. While 
it is unquestionably true that in a certain number of cases these per- 
sistent bacilli are non-virulent, the opposite has been frequently shown. 
64 



994 THE SPECIFIC INFECTIOUS DISEASES. 

Of 15 eases in which the virulence was tested, virulent bacilli were found 
in 9 at periods varying from eight to twenty-five days after the mem- 
brane was gone. 

Treatment of Suspected Cases. — During an epidemic of diphtheria, 
especially in an institution, every sore throat and nasal discharge should 
be looked upon with suspicion, and isolated pending the result of a bac- 
teriological examination, even though no membrane is present. If there 
are patches on the tonsils or any other visible membrane, the case should 
be treated as true diphtheria, in order that no time may be lost. If the 
bacteriological examination shows the disease not to be true diphtheria, 
the patient may be released from quarantine in two or three days, pro- 
vided the throat symptoms disappear. It is, of course, important that 
the conditions laid down with reference to bacteriological diagnosis shall 
have been fulfilled. Should S}miptoms continue, however, a second cul- 
ture should be taken. 

Immunisation of Persons Exposed. — When a case of diphtheria occurs 
in a family or an institution, every child that has been exposed should 
receive an immunising dose of antitoxine. This rule is not followed in 
practice as regularly as it ought to be. There is no doubt that for a 
limited time — from two to three weeks — the serum confers almost com- 
plete protection. 

One need not hesitate to immunise persons of any age and in almost 
every condition, even newly-born infants and pregnant women. 

The dose for immunisation is from 500 to 1,000 units, the former 
being that required for an infant, and the latter for older children. If 
the exposure is continuous, as in an institution, the dose should be re- 
peated every three or four weeks. A nurse in charge of a diphtheria 
case should receive 1,000 units. 

Diphtheria so often complicates scarlet fever and measles, particu- 
larly in institutions and in hospitals for contagious diseases, that special 
consideration should be given to such patients. It is practically impos- 
sible by cultures to separate with absolute certainty all cases in which 
diphtheritic infection is present, from others; the only safe rule is to 
immunise every child admitted to a scarlet-fever or measles hospital, 
and in institution epidemics of either of these diseases to immunise 
every child attacked. 

Xurses and Physicians. — As diphtheria is contracted, not from the 
breath of the patient or the air of the room, but by receiving the bacilli 
into the mouth or air passages, all possible means should be taken to 
destroy the bacilli discharged, and to secure absolute cleanliness in every- 
thing about the sick-room. When it can possibly be avoided, nurses 
should not be allowed to eat or sleep in the sick-room, and an antiseptic 
gargle should be used. The hands should be kept clean, and only such 
dresses worn as can be readily washed and disinfected. It is the nurse 



DIPHTHERIA. 995 

who is most likely to contract the disease, on account of the continued 

exposure. 

The physician should take the same precautions as in Bcarlel f< 
A poeket tongue-depressor should qoI be used for the throat, bui a 

wooden depressor or a spoon kept in a solution of carbolic acid. 

The Sick-room. — The carpels, hangings, upholstered furniture, every- 
thing in fact not necessary for the patient's welfare, should be removed. 

The room should he a large one, well ventilated, and fresh air should be 
allowed in abundance. The floor should be washed once a day with a 
solution of bichloride, 1 to 2,000, and dusted often with cloths moistened 
in the same solution. All handkerchiefs, bed-linen, and clothing re- 
moved from the patient should be treated as in a case of scarlet 
Pieces of membrane and other matters discharged from the patient 
should be burned. Old muslin or absorbent cotton should be used to 
cleanse the nose and mouth of the patient and burned immediately. All 
vessels for the reception of expectoration or other discharges should con- 
*tain bichloride, 1 to 2,000. The bed-linen should be very frequently 
changed, and everything kept scrupulously clean. In the room should be 
a large bowl of carbolic acid, 1 to 40, or some similar solution for cleans- 
ing the hands, and a tray of the carbolic solution for spoons, Byring 
other things used in the treatment of the patient. All spoons, cups, or 
other dishes used by the patient should be carefully sterilised by boiling. 
No milk or other food should be allowed to stand about the room. There 
is no objection to the hanging of sheets moistened in carbolic, bichloride, 
or other disinfectant solutions before the door, but neither this nor 
hanging them about in the sick-room is to be regarded as having any 
value in disinfecting the air of the room. They create a false Bense of 
security, and often lead to the neglect of thorough clean 1 in 

Disinfection of apartments after an attack should be done as after 
scarlet fever. 

Treatment. — General Measures. — It is important in every ease that 
there should be plenty of fresh air in the room throughout the attack. 
Hospital patients should never have less than 1,000 cubic feet of air space, 
and if possible 1,200 should be allowed. Even in mild cases the patient 
should be kept in bed throughout the entire attack, and in severe cases 
this should be continued for some time during convalescence. 

Xursing infants may be fed on breast-milk obtained by a hi 
pump, but should not be put to the mother's breast. The feeling of 
older children should be managed very much as in other cases of - 
illness. Milk is the main reliance; it should usually be diluted. The 
greatest difficulty in feeding is seen in the latter part of the disease, when 
the patients are septic and have a strong aversion to food, when vomit- 
ing is easily excited and when swallowing is difficult on account of the 
swelling and pain. It is then that gavage is most valuable. This is much 



996 THE SPECIFIC INFECTIOUS DISEASES. 

more successful with children under three years old than is rectal feed- 
ing. In older children the tube may be passed through the nose. 

Stimulants. — In most cases they are not needed until the third or 
fourth day, and in some they may not be required at all. The indica- 
tions for stimulants are marked prostration, a feeble pulse, and a weak 
sound of the heart. Of alcohol, half an ounce of whisky or brandy 
in twenty-four hours is enough to begin with, for a child four years 
old. This should be diluted with at least eight parts of water. In 
very severe cases two or three times as much may be given; but more 
than this, except for a short period, is seldom wise. More reliance is to 
be placed upon the other circulatory stimulants, especially caffein, cam- 
phor, and digitalis, which are given for the same indications as in other 
acute diseases. In cases of threatened cardiac paralysis occurring late 
in the disease or during convalescence, morphine should be used hypo- 
dermically. Full doses must be given and repeated every two to four 
hour's, so that the child may be kept under its influence. 

Except for stimulation or the control of special symptoms such as 
vomiting or diarrhoea, all internal medication should be omitted; for 
there is yet wanting proof that drugs influence the course or the result 
of the disease. 

Local Treatment. — Since the introduction of antitoxine, opinion has 
undergone a decided change with reference to local treatment. While 
it should not be entirely abandoned, still it is of secondary importance; 
and under conditions when it can be carried out only with great diffi- 
culty and the use of force it is often wise not to attempt it regularly. 

The purpose of local treatment, it is now generally agreed, should be 
cleanliness, and not the destruction of bacilli. Cleanliness of the nose, 
mouth, and pharynx is important, inasmuch as one of the chief dangers 
of the disease is the aspiration of bacteria contained in the abundant 
secretions of these parts, into the larynx and bronchi. Our aim should 
therefore be to keep the parts as clean as possible without too severely 
taxing the strength of the child. 

For cleansing the nose and pharynx only syringing can be depended 
upon. Nasal syringing is indicated when there is much nasal discharge, 
whether membrane is visible in the anterior nares or not. In septic 
cases with a profuse foetid discharge it may be necessary to syringe the 
nose, no matter how strongly the child resists. Whether it shall be 
done, will depend upon the condition of the patient's strength and his 
pulse. The purpose in syringing is not so much to clear the nose, from 
which absorption is slow and imperfect, as to flush the rhino-pharynx, 
from which absorption is always very active. Only bland solutions 
should be employed, such as a saline solution, one per cent, or a boric- 
acid solution, one- to four-per-cent strength. For some cases, the piston 
syringe may be used; but for most a fountain syringe possesses man- 



DIPHTHERIA. QQ7 

ilVsf advantages, and it is rather more convenient for hospital par 
poses. Irrigation of the pharynx is best done with the fountain syringe, 
and is of especial value where there is much swelling or abundant dis- 
charge. All solutions should be used as warm as can be borne, and in 
sufficient quantity to irrigate the parts thoroughly, a feu such Irrigations 
being much better than a great many partial ones. By a skilful nurse 
syringing can in most cases be done with comparatively little disturbance 
to the child. 

Slight nasal haemorrhages may necessitate less frequent Byringing, 
and a free haemorrhage may require it to be discontinued. Astringenl 
solutions of alum and adrenalin are often beneficial in such cases, hut 
they must be used carefully. In children who are old enough gargles 
should be used. A solution of boric acid, or Dobell's or Seller's solution 
much diluted, may be employed. 

In cases with a moderate nasal discharge it is usually Bufficienl to 
syringe three or four times a day; but in severe septic cases, with very 
abundant discharge, syringing should be repeated as often as every two 
hours during the day and every four hours at night. 

External applications to the throat have practically no effect upon 
the disease, but are often useful to relieve pain and tension in the 
swollen lymph-glands. Poultices should not be employed. As a con- 
tinuous application, only cold is to be advised, generally by means of an 
ice-bag well protected to prevent wetting the clothing. 

The treatment of cardiac and other forms of post-diphtheritic paral- 
ysis has been considered in the chapter on Multiple Neuritis. 

The Serum Treatment. — This has been the outcome of a long series 
of experiments in which many men have had a share; but it is to He br- 
ing pre-eminently that the credit belongs for the development of the 
principles of serum-therapy. 

Antitoxine is produced by the cells of the body under the stimulus 
of the diphtheria toxine. It is intimately combined with the globulin 
of the blood, and is itself possibly a globulin. It directly neutralises the 
toxine produced by the diphtheria bacillus, and also has some effect upon 
the bacilli themselves, the nature of which is not understood. It in- 
duces a condition in the blood which inhibits the growth of the bacilli, 
and thus arrests the membranous inflammation which they excite. 

Properly prepared, it will keep without deterioration for from three 
to six months; but after one year it loses somewhat its antitoxic- prop- 
erties. It should be kept in a cool, dark place, and after a bottle has 
been opened it should be used within a few days. Antitoxine is now 
prepared in a dry form, which is to be preferred only when it must he 
kept for a very long time. 

The strength of the serum is measured in antitoxine units, the unit 
being an arbitrary one, viz., the amount of antitoxine which will protect 



998 THE SPECIFIC INFECTIOUS DISEASES. 

a guinea-pig weighing 250 to 300 grammes against one hundred limes the 

fatal dose of diphtheria toxine. The improvements in the production of 
the serum have thus far consisted in increasing its strength. Behring's 
serum first used contained hut one unit in each cubic centimetre. At 
present there can be obtained sera containing 1,000 antitoxine units in 
each cubic centimetre. This concentration is of immense advantage and 
has to a large degree done away with the unpleasant symptoms. 

Method of Administration and Dosage. — Before making the injection, 
the skin should be thoroughly cleansed with alcohol; the needle should 
invariably be boiled and the whole syringe either boiled or rinsed with 
alcohol. The seat of injection is not a matter of great importance; my 
own preference is for the cellular tissue of the abdomen or the muscles 
of the buttock. Absorption from the cellular tissue is slower than from 
the muscles. For very rapid effect, intravenous injections should be 
employed. After the injection is made the puncture should be covered 
by adhesive plaster. 

It is desirable to give enough antitoxine to neutralise the diphtheria 
toxine present in the blood, but no amount can neutralise the toxine 
which has already become fixed to the cells, except to a very slight degree. 
What can be accomplished is to supply the blood with sufficient antitoxine 
to neutralise new toxine as fast as it is produced. Convinced now of the 
essential harmlessness of the serum, the tendency everywhere has been 
to use larger and larger doses. For a child over two years old an initial 
dose for a severe attack, including all laryngeal cases, should not be less 
than 7,000 or 8,000 units, repeated in from six to eight hours, provided 
no improvement is seen. Children under two years should receive from 
5,000 to 6,000 units. Cases of exceptional severity, in older children, 
should receive from 10,000 to 15,000 unitsj to be repeated in from six 
to eight hours if the progress of the disease is unfavourable. Mild cases 
should receive from 3,000 to 5,000 units as an initial dose, a second 
being rarely required. 

In cases receiving antitoxine late, even though the symptoms may 
not seem particularly severe, the dose should be increased in proportion 
to the length of the illness — i. e., if three days ill, three times the or- 
dinary dose should be given. 

Only serum from a trustworthy manufacturer should ever be used. 
The most concentrated serum which can be obtained should be se- 
lected. 

All experience shows that the results are greatly modified by the 
time of its administration. The serum can not undo the serious damage 
already done to the cells of the body, and this at the time of injection 
may be so great that death will result. In very mild cases, with older 
children, one may wait for the result of a bacteriological examination, 
but never in a severe case and never in a young child. In the group of 



DIPHTHERIA. QQQ 

severe cases should be placed every one which at the first visit ah 
pharyngeal exudate covering more than the tonsils, also all cases with 
symptoms of laryngeal invasion, and all with an exudate od the pharynx 
and a profuse nasal discharge. If in a doubtful case twelve hours' ob- 
servation shows that the membrane has spread from its original seat, no 
further delay is admissible. In human diphtheria marked benefit usually 
follows injections made as late as the third day; but after this time the 
value of the serum diminishes very rapidly, and although striking ex- 
amples of benefit are sometimes seen after later injections, they can not 
be depended upon. In very severe or in malignant eases bo much harm 
may be done during the first twenty-four hours of the attack that the 
subsequent use of antitoxine is without avail. 

The effect upon the diphtheritic membrane is usually noticeable 
within twenty-four and often in twelve hours; it first stops spreading, 
and soon begins to soften and loosen. The swelling of the mucous mem- 
brane subsides and the local disease abates, very much as when the dis- 
ease runs its usual course. The striking thing after the use of antitoxine 
is the rapidity with which these changes take place, and the abrupt tran- 
sition from an advancing to a retrograde process. The subsidence of 
the inflammatory conditions in the larynx and trachea is quite as marked 
as in the pharynx. The symptoms of stenosis, even when severe, often 
diminish in a few hours, making operation unnecessary in a very Large 
number of cases when previously it seemed inevitable. The membrane 
loosens rapidly in the larynx and trachea, sometimes necessitating the 
frequent removal of the intubation tube, when operation lias been per- 
formed. Improvement is also shown by the cessation of the nasal dis- 
charge, the re-establishment of nasal respiration, and the diminution in 
the swelling of the glands of the neck. 

The effect upon the constitutional symptoms is not less striking. In 
favourable cases there is seen, often in twelve hours, a fall in tempera- 
ture and improvement in the pulse and in the nervous symptoms. 

The Limitations of Antitoxine. — It is important that these should 
always be kept in mind. The serum must be given early, for if given 
late it can not undo the mischief already done by the diphtheria toxine. 
Cases of great severity often pass the period when recovery is possible, 
before the antitoxine is given. This period may in some eases he four 
days, in others it may be less than twenty-four hours. The tissues most 
susceptible to the diphtheria toxine are probably those of the nervous 
system, the heart, and the kidneys; and the consequences of its action 
may be seen in the production of nephritis, in heart failure at the height 
of the disease, or in later paralysis of the heart, respiration, or the volun- 
tary muscles, in spite of the fact that antitoxine is given at a period early 
enough to avert death from local disease in the larynx or bronchi 
Against the phlegmonous inflammation of the throat or the cellular 



1000 THE SPECIFIC INFECTIOUS DISEASES. 

tissue of the neck, broncho-pneumonia, and nephritis, antitoxine is pow- 
erless : ami just in proportion to the severity of these inflammations are 
negative results seen. 

Eruptions and Other Unpleasant Effects. — Some transient, local 
oedema usually follows the injection and a slight rise of temperature is 
very frequently observed. In a few hours there may be seen a general 
erythema ; this, however, is rare and usually of short duration. The 
most important eruptions are seen between the eighth and fourteenth 
days. They follow from ten to twenty per cent of the injections made, 
and appear to be quite independent of the amount of serum used. The 
exact cause is not known. The most common eruption is urticaria. This 
is often intense, very annoying, and may nearly cover the body. It may 
be accompanied by a slight rise of temperature; it usually lasts for two 
or three days; however, it is rarely severe for more than twenty-four 
hours. Various forms of erythema are occasionally met with. In two 
or three instances I have seen hasmorrhagic eruptions, generally in the 
neighbourhood of the large joints, and always in children suffering 
from extreme malnutrition. In a few cases a moderate swelling of some 
of the joints has been observed, and very exceptionally a transient albu- 
minuria. One occasionally meets with patients who seem unusually 
susceptible to serum injections, and in whom even small immunising 
doses cause headache, muscular pains, and general malaise, so that they 
feel quite wretched for several days. All of the above symptoms except 
the urticaria are rare, and should not for an instant deter one from using 
antitoxine when indicated. 

Real and Alleged Dangers from Antitoxine Injections. — In a few in- 
stances sudden death has followed antitoxine injections, but the evidence 
that antitoxine was the cause of death has not always been conclusive. 
In some of these patients the autopsy has revealed a status lymphaticus 
not before suspected. In this condition the shock of so slight a thing 
as a needle puncture may produce death. There are other cases which 
do not admit of this explanation. Almost all have occurred in patients 
during adolescence or adult life. So many of these patients have been 
asthmatics that the association can hardly be an accidental one ; and curi- 
ously some of these patients have had the form of asthma excited by con- 
tact with horses. The symptoms usually come on within a few minutes 
after the injection, and occur quite independently of the dose given. 
Several have followed small immunising doses given to apparently 
healthy persons. The most striking symptoms are a rapidly developing 
dyspnoea with cyanosis and great prostration. In the most severe cases 
death may follow in a few minutes from suffocation ; in those less severe, 
a gradual recovery takes place with no permanent after-effects. The 
most effective treatment is atropine, hypodermically, in full doses, com- 
bined with artificial respiration. 



DIPHTHERIA. 



1001 



That so very few reported instances of serious harmful results have 
occurred among the great numbers of injections which have been 

made, is sufficient to establish the fact that the serum itself i^. in 
the vast majority of instances, quite harmless. Certainly in children 
one should not hesitate one moment in regard to its use. In an 
asthmatic patient, if antitoxine is given, atropine should he injected 
simultaneously. 

Results wilh Antitoxine Treatment. — Since 181).") the serum has been 
tested on such an extensive scale as the prevalence of diphtheria all over 
the world has made possible, with results so uniformly good that it seems 
quite unnecessary any longer to cite statistics in proof of the value of 
this remedy. ISTo tables of figures are so convincing to an individual as 
personal experience, and by this argument one by one the opponents of 
antitoxine have been converted. 

The beneficial effects of the remedy may be summed up in the follow- 
ing statements: (1) The percentage mortality from diphtheria in hos- 
pitals both in Europe and in America has been reduced to a little more 
than one-third the previous figures; (2) the proportion of cases now 
requiring operation for laryngeal stenosis has been reduced to about 
one-half; (3) the mortality after tracheotomy has been reduced to one- 
half, and that after intubation to about one-third the former figures; 
(4) but even more convincing is the effect of the serum treatment upon 
the actual diphtheria mortality of cities and countries where it has 
been used. 

In the first of the subjoined tables is given for a period of years the 
actual number of reported deaths from diphtheria and membranous 
croup, irrespective of the growth in population; in the second one the 
number of deaths in each 10,000 of population. These figures can not 
be open to the question which is sometimes raised concerning percentage 
mortality statistics. 

Table Showing Annual Deaths from Diphtheria and Croup, 
before and since the Use of Antitoxine. 



London .... 

Berlin 

Paris 

New York . . 

(Manhattan and 
Bronx) 

Chicago .... 

Boston 

Philadelphia 
Brooklyn. . . 
Denver. . . . 
Germany. . . 

(266 towns over 
15.000) 

N. Y. State. 
Mass 



1887 188S 1889 1890 1891 1892 1S93 1894 1895 1896 1897 L898 L899 1900 



1,579 
1,392 
1,585 
3,056 

1,405 

410 

858 

1,453 

68 

10,970 

6,490 
1,628 



1,812 
1,195 
1,729 
2,553 



,710 
,831 



2,075 
1,210 
1,706 
2,291 



1,509 
683 
727 

1,467 

109 

11,919 



5,930 
2,214 



1,877 
1,601 
1,659 
1,783 

1,261 
462 
748 

1,283 

277 

11,915 

4,954 
1,626 



1,174 
1,106 
1,361 
1,970 

1,358 

285 

1,362 

1,180 

175 

10,484 



2,182 
1,342 
1,403 
2,106 

1,548 

481 

1,707 

1,137 

89 

12,365 



4,844 5,970 
1,218 1,455 



3,484 
1,637 
1,206 
2,558 

1,476 
546 

1,238 

878 

106 

16,557 

5,942 
1,394 



2,861 2,179 
1,41 ti 987 
1,009 435 
2,870 1,976 

I 



460 1 

878 
,452 1 
i)(H) 1 

71 
,790 7 

6165 

S01 1 



,632 
654 
,398 
.451 
40 
,611 



784 



2,793 2,328 1,842 2.011 1,558 

559 510 004 <>" 

Ill 20S 250 336 291 

1,703 1,591 843 900 1,121 



1,098 

572 
1,201 
1,310 

19 
0,202 

4,040 
1,077 



771 684 
450 185 

1,514 1,154 

43 34 



917 
304 

997 
7)1 

::i 



5,2085,220 ."..ill 



797 
11 



1,115 2.012 2 

1,426 70ffl l l,047r* 1,478 



1 Cases reported 1899, 7,134. 



2 Cases reported 1900, 12.011. 



Paris. 


6.5; 


Now York, 


14.5; 


Chicago, " 


13.1; 


Denver, 


12.9; 


Philadelphia, " 


1890-'94, 11.9; 



1002 THE SPECIFIC INFECTIOUS DISEASES. 

Tabic Showing Average Annual Deaths from Diphtheria and Croup 
per 10,000 of Population. 

London, before antitoxine, 1887-93, 4.8; since antitoxine 1896-1900,4.7 
Berlin, " " 10.2; " " 3.7 

1.3 
6.3 
5.0 
1.7 
9.6 

Some explanation of these figures is necessary that they may be fully 
appreciated. The great reduction in the death-rate is seen only in those 
cities and countries where the serum treatment has been widely employed. 
Xowhere in Europe is this true to the same degree as in Paris, Berlin, 
and Germany generally; and probably nowhere in Europe was it so 
little used and so slow in gaining favour as in London. In our American 
cities the effect of the serum treatment upon municipal mortality figures 
has been directly proportionate to the extent to which the health depart- 
ments have believed in its efficacy and encouraged its use by furnishing it 
free to the poor, and sending their own inspectors to administer it. This 
is true particularly of New York and Chicago; in Philadelphia, on the 
contrary, the authorities for a long time were openly opposed to the 
serum treatment. 

Convalescence. — After a severe attack of diphtheria convalescence is 
always slow on account of the anaemia and the depressing effects of the 
disease. Patients should invariably be kept in bed for at least a week 
after the throat has cleared, and longer if any tendency to cardiac weak- 
ness is seen. The pulse should be carefully watched, and irregularity, 
intermission, dicrotism, or a weak first sound of the heart, should make 
one apprehensive. An abnormally slow pulse is generally more serious 
than one which is rapid. Under such circumstances the patient should 
be kept recumbent and absolutely quiet, since sudden and even fatal 
syncope may be the result of a violation of these rules. 

The extreme degree of anaemia requires that iron be given for a 
considerable time during convalescence, to be followed by cod-liver oil 
and other tonics. 

Great difficulty is occasionally experienced in getting rid of the 
bacilli in the throat. The tonsillar crypts, the adenoid tissue of the 
rhino-pharynx, and the nasal sinuses are the places where the bacilli are 
most likely to remain. Inasmuch as it is now generally made a condition 
of release from quarantine that the throat shall have been shown by 
cultures to be free from bacilli, this becomes a matter of much im- 
portance. The most efficient means appears to be to syringe the nose 
gently three or four times daily with a solution of bichloride, 1 to 10,000, 
to which one-eighth glycerin has been added, and to use the same solution 



INTUBATION. 



wo:* 



as a gargle. For children under four years old a simple sail solution, or 
a dilute DobelPs solution, should be substituted and the gargle omitted. 

Laryngeal Diphtheria. — Emetics, inhalations of Bteam, and solvents 
for the membrane, although they all sometimes give relief, are not to be 
relied upon. 

Opinions will always differ as to the time when operative inter- 
ference is called for. One should never wait for general cyanosis, for 
often this does not occur until just before death. It is better to operate 
too early than too late. If, in spite of other measures, the dyspnoea in- 
creases steadily, operation should not be deferred longer. Intubation has 
almost universally superseded tracheotomy as a primary operation for 
the relief of membranous laryngitis. Tracheotomy is still needed at 
times for the cases, very few in number, in which intubation fails to 
give relief on account of the position of the membrane or some other 
complication. 

Intubation. 

Intubation is the introduction of a tube through the mouth into the 
larynx for the relief of laryngeal dyspnoea. For the operation, as now- 
performed, the world is indebted to the late Dr. Joseph O'Dwyer, of 
New York. 




Fig. 199, 



'Dwyer's Intubation Set. 



A set of O'Dwver's instruments (Fig. 199) consists of seven tubes, an 
introductor, an extractor, a mouth-gag, and a gauge. The tubes are made 
of hard rubber and lined with gold-plated metal. So carefully did 



1004 THE SPECIFIC INFECTIOUS DISEASES. 

O'Dwyer perfect his instruments that nothing of importance has been 
added h\ others. It is interesting to note that nearly all the modifica- 
tions which have been suggested since his first publication had already 
been tried by him and discarded. No one thing is more essential to 
success with intubation than properly constructed instruments. The 
operation is not difficult, if one has had practice on the cadaver. With- 
out this it should not be attempted. The tube is selected according to 
the age of the patient, this being indicated on the gauge. A very large 
child will often require a tube of larger size than its age would call for. 

Introduction of the Tube. — Either one of two positions may be em- 
ployed, the choice depending upon the preference of the operator. For- 
merly the usual method was to have the child seated upon the lap of a 
nurse while his head was steadied by a second assistant standing behind. 
In the other position the child lies upon his back upon a table, his head 
being steadied by an assistant. In both positions the arms should be 
pinioned to the sides by a sheet. In the recumbent position the child 
can be held more firmly; it has also the advantage of dispensing with 
one assistant, and in an emergency with both of them. The tube is 
attached to the introductor, and the gag is inserted into the left angle 
of the mouth and opened as widely as possible. The slipping of the gag 
and laceration of the mouth may be prevented by using a piece of rubber 
tubing to cover each arm of the gag where it comes in contact with the 
gum. The attempts at introduction must be made quickly, for during 
them respiration is practically arrested. Several short attempts are 
always better than a single prolonged one. Yery little force is ordinarily 
required in introducing the tube, that used in passing a catheter being 
a good general guide. In cases of subglottic stenosis, however, quite a 
little force may be necessary. 

The index finger of the left hand is used as a guide in introduction. 
This is passed well back into the pharynx, then brought forward until a 
hard nodule — the upper border of the cricoid cartilage — is encountered. 
This is the best of all landmarks, since the soft parts are often distorted 
by swelling. Directly in front of the cricoid cartilage may be felt the 
epiglottis and the opening of the larynx, which are readily recognised 
after the touch has become somewhat educated. The epiglottis is drawn 
forward and the tube is passed along the palmar surface of the left index 
finger, by which, it is guided into the larynx; it is then pushed off the 
introductor by a thumb-piece attached to its handle. When it is certain 
that the tube is in position, and the patient breathes properly, the loop 
of silk attached to the head of the tube is cut off and pulled through, 
the removal of the tube being prevented by placing the left forefinger 
upon its head. The silk is not usually left attached unless there is evi- 
dence of loose membrane below the tube. It may be desirable to leave 
the silk attached in case no one can be within reach who is able to remove 



INTUBATION, L005 

the tube should it become obstructed. The child's arms and bands should 
then be secured to prevent him from seizing it himself. When not re- 
moved the silk is fastened to the cheek by a piece of adhesive p] 
The tube is known to be in place, first, by the hissing breathing Bounds, 
somewhat similar to what is heard when the trachea Is opened ; secondly, 
by a severe paroxysm of coughing, which is usually excited by a lube in 
the larynx; thirdly, by the relief of the dyspnoea. It' this relief if not 
very apparent the physician may still be in doubt as to whether the tube 
is in the larynx or the oesophagus. If in the former, it can not be pushed 
down by the finger without depressing the larynx with it ; and by in- 
troducing the finger into the pharynx, the posterior wall of the larynx 
can be felt between the finger and the tube. The most common mistake 
made is to pass the tube into the oesophagus. This sometimes happens 
because the position of the child's head is improper — too far forward or 
too far backward — but more often because the operator has not been quite 
sure of his landmarks. If this has occurred, there is no relief to the 
dyspnoea, no hissing sound, and the tube can be pushed down indefinitely. 
When this condition is recognised, the tube is withdrawn by the loop of 
silk and after a few moments a second attempt made. 

False passages in the larynx are most frequently made by employing 
too much force or because the operator has worked at the angle of the 
mouth instead of keeping in the median line. The tube usually goes 
into one of the ventricles, and may be pushed quite through the larynx 
into the cellular tissue. This is not likely to happen unless undue force 
has been used. The production of a false passage is recognised by the 
fact that, although the tip of the tube can be felt to enter the larynx, 
it does not descend, but projects above the epiglottis. 

False membrane which has become loosened is sometimes crowded 
down by the tube and obstructs the larynx just below it. This is one of 
the most serious accidents that may occur, but fortunately it is not a 
frequent one. It is more likely to happen when the disease has existed 
for several days than in recent cases. The tube may be in place in the 
larynx as shown by all the signs above mentioned, except relief of the 
asphyxia. In such a case the immediate withdrawal of the tube is neces- 
sary, it being often followed by the discharge of masses of loose mem- 
brane. This is aided by the administration of half a teaspoonful of pure 
whisky or brandy to excite a strong cough. Artificial respiration may ho 
required, and if there is no relief by any of these means tracheotomy is 
indicated. Asphyxia is sometimes produced by prolonged and injudicious 
attempts at intubation. 

After-treatment.— So far as the tube itself is concerned no treat- 
ment is required. The original disease is to be treated as before. The 
operation has removed only one danger from the patient, viz., that of 
asphyxia from mechanical obstruction of the larynx. A good expulsive 



1006 THE SPECIFIC INFECTIOUS DISEASES. 

cough should occur after the tube is in place. This is necessary to clear 
the tube of mucus, as the pharynx and larynx are generally filled with 
it as a result of the manipulation. 

The child should not be allowed to lie upon his face, nor should he 
be held over the nurse's shoulder face downward, for in either position 
a slight cough is enough to expel the tube. Nursing infants may some- 
times continue at the breast after the operation ; ordinarily they have but 
little difficulty in swallowing. Older children often experience consider- 
able trouble in taking liquids. This may be overcome by the device sug- 
gested by Casselberry, of having the patient's head lower than his body 
while he drinks. When fluids cause excessive coughing or at other times 
when they can be taken only with the greatest difficulty, they may be 
given through a nasal tube or one passed through the mouth. Semi- 
solid articles, such as condensed milk, wine jelly, corn starch, ice cream, 
or scrambled eggs, may be well taken when fluids are not. Feeding is 
always easier after the first day or two, and patients who wear a tube 
for chronic disease soon experience no trouble whatever, showing that the 
difficulty depends more upon the inability to co-ordinate the movements of 
the muscles of deglutition when the tube is in place than upon mechanical 
causes, for the head of the tube is effectually covered by the epiglottis. 

It sometimes happens that the tube is coughed out soon after its 
introduction, because too small a size has been used. In some cases this 
occurs repeatedly. It happened in a case of my own twenty-eight times 
during four days. Such cases are probably due to paralysis of the laryn- 
geal muscles. The dyspnoea does not usually return for two or three 
hours after the tube has been coughed out, but may come back at once. 
It may happen that the tube is coughed up and not seen by the nurse, 
or it may be coughed up and swallowed by the child. When called be- 
cause of dyspnoea after operation, the physician should make a digital 
examination of the pharynx to be sure that the tube is still in place. 
Swallowing the tube generally causes no harm to the child, for tubes have 
repeatedly passed through the intestines. 

The entrance of food into the bronchi through the tube is a danger 
that does not exist, and broncho-pneumonia following intubation does 
not depend upon the entrance of food into the bronchi. 

Deep ulceration at the head of the tube very rarely occurs, provided 
properly made tubes are employed, but superficial ulceration almost in- 
variably is produced at the base of the epiglottis and in the trachea at 
the lower end of the tube. Deep ulcers extending to the tracheal rings 
may occur in ill-conditioned children, usually in connection with other 
complications serious enough to cause death. 

Spontaneous descent of the tube into the larynx is almost impossible, 
and it can not be crowded down without using considerable force and 
severely lacerating the larynx. 



INTUBATION. 1007 

Sudden blocking of the lower end of the tube by membrane loosened 
from the trachea or bronchi occasionally occurs. The usual result of 
this is the immediate expulsion of the tube by coughing, the discharge 
of the loose membrane following. This condition is one of the safety 
valves of the operation. One of the strong points in favour of intul na- 
tion is that the forcible cough which the patient is able to make on 
account of the narrow opening of the tube, often enables him to expel 
large accumulations of mucus, and even membrane, more readily than 
through a much larger tracheal opening. 

The period for which the tube is required varies much in different 
cases. It is the experience of practically all operators that it has been 
materially shortened by the use of antitoxine. The average time of wear- 
ing the tube is about five days, and in many it can be dispensed with in 
two or three days. Should the tube be coughed out at any time, its 
introduction should be delayed until dyspnoea returns. 

Removal of the Tube — Extubation. — This is rather more difficult than 
its introduction. The general arrangement of the patient and assistants 
is the same as for introduction. The left index finger is placed upon 
the head of the tube, which is steadied externally by the thumb of the 
same hand. The beak of the extractor is introduced within the opening 
of the tube, its jaws are then separated by pressure upon the lever at the 
handle, and the instrument withdrawn, very slight force being required. 

The tube is first removed tentatively, the physician waiting to see if 
dyspnoea returns. It is well to give a full dose of morphine an hour 
before the removal of the tube, since this operation is almost invariably 
followed by a marked degree of laryngeal spasm which lasts for ten or 
fifteen minutes. To avoid the production of vomiting and the entrance 
of food into the larynx, food should not be given for two hours previ- 
ously. If dyspnoea does not return in the course of three or four hours, 
the probabilities are that the tube will no longer be required. It is excep- 
tional that the patient has great difficulty in dispensing with the tube, 
as so often happens after tracheotomy. 

The only objection of much force urged against intubation is that 
asphyxia may be produced by crowding down loose membrane into the 
larynx. This is an infrequent accident; should it happen, and the 
asphyxia not be relieved by removing the tube and inserting another, 
tracheotomy may be performed. 

There is always some degree of hoarseness following intubation, but 
in the majority of cases it disappears within a week, occasionally it con- 
tinues as long as three or four weeks, but it is very rarely if ever perma- 
nent. The duration of the aphonia seems to have little relation to the 
length of time the tube is worn unless this is many weeks. 

Experience has clearly proved that intubation relieves the dyspnoea 
due to laryngeal stenosis promptly, efficiently, and certainly ; it does this 



1008 THE SPECIFIC INFECTIOUS DISEASES. 

without many of the dangers and objectionable features of tracheotomy, 
while at the same time it does not deprive the patient of any essential 
advantage which tracheotomy affords. 

Retained Intubation Tubes — Prolonged Intubation. — Difficulty is ex- 
perienced in dispensing with the intubation tube much less frequently 
than with the cannula after tracheotomy; yet when this condition occurs 
it is the cause of much concern and even danger. Trouble of this sort 
is seen in about one per cent of the cases of intubation. In the majority 
of these the patient is able to do without the tube in a few weeks, and* 
such cases require very close attention, but no special treatment other 
than the substitution at times of a special O'Dwyer tube with an extra 
large " retaining swell/ 7 But occasionally there are met with cases in 
which every effort to dispense with the tube proves futile. Although 
the children breathe well with the tube in place, still if it is removed 
or expelled by coughing, in a short time, varying from a few minutes to 
several days, the dyspnoea returns with such severity that the tube must- 
be replaced to prevent asphyxia. Inasmuch as these patients sometimes 
expel the tube several times a day, surgeons have often resorted to trache- 
otomy to avert the danger of suffocation, which might easily occur if no 
one were at hand who could replace the tube. This operation, however, 
gives only temporary relief. Many of these children, after wearing 
tubes of one sort or another for years, ultimately die from some accident 
connected with the tube or from pneumonia. 

The causes and the exact pathological condition underlying this dif- 
ficulty are subjects regarding which there has been much difference of 
opinion. The cause of the returning dyspnoea is probably subglottic 
swelling and oedema which occur in tissues which are the seat of chronic 
inflammation as soon as the pressure of the tube is removed. In a few 
cases a cicatricial condition, the result of previous ulceration, has been 
found ; but it is doubtful if granulations, so frequent a cause of retained 
cannula after tracheotomy, play a part. The chronic inflammation of the 
mucous and submucous tissues of the subglottic region of the larynx 
which produces the symptoms, is aggravated by a faulty tube or a clumsy 
operation, but it may occur under the most favourable conditions. 

For the relief of this condition, O'Dwyer advised in recent cases the 
application of astringents by means of an intubation tube coated with 
gelatine with which some astringent was combined. For those patients 
who cough out the tube frequently, tracheotomy is at times a necessity 
to prevent sudden death. But this does not affect the original condition, 
for the same difficulty exists in doing without the tracheal cannula. The 
operations of laryngotomy, curetting, etc., have been such signal failures 
as to discourage one from repeating them. 

The most successful method of treatment thus far proposed is that 
of Rogers, which consists in increasing intra-laryngeal pressure by the 



TYPHOID FEVER. 1009 

insertion of larger and larger intubation tubes. This is Dot to be adopted 
until long after all acute symptoms have subsided. The first tube usee! 
is as large a one as can be introduced without force; after a few weeks, 
the next larger size, and after a longer interval, possibly a Btill Lai 
one. When the very large tube has been worn lor several week- one is 
usually able to dispense with all tubes. 

True cicatricial stenosis may best be relieved by opening the trachea 
and dilating from below, and afterward inserting an intubation tube. 
When there is complete destruction of the cricoid cartilage, as sometimes 
occurs, tracheotomy is the only remedy, but this is only palliative, as 
the tube must be worn permanently. 



CHAPTER IX. 
TYPHOID FEVER. 

Typhoid fever is an acute infectious disease due to a specific germ 
— Eberth's bacillus. It may affect the foetus in utero, or the newly- 
born child, and it is seen in infancy and throughout childhood. 

Foetal Typhoid. — Morse has collected the evidence bearing upon foetal 
infection, from which the following conclusions seem warranted : Infec- 
tion of the child from the mother is a frequent but not an invariable oc- 
currence. The bacilli may pass directly from the maternal into the foetal 
circulation. The foetal form of the disease is a general blood-infection, 
since the intestines are not functionally active. The most common 
result is death of the foetus and consequent abortion; but the child may 
be born alive still suffering from infection, and die in a short time be- 
cause of its feeble resistance. 

Infantile Typhoid. — Much difference of opinion exists regarding the 
frequency with which typhoid fever occurs in infancy. Some clinicians 
hold the opinion that the disease is of very common occurrence, but is 
often unrecognised because of the absence of many of the symptoms 
which are characteristic at a later age. They regard every protracted 
fever not malarial and not dependent upon a local inflammation as pre- 
sumably typhoid. The symptoms from which we may regard the ques- 
tion of typhoid as established will be considered under Diagnosis. I have 
seen but two undoubted cases of typhoid under two years of age, and I 
believe it to be rare, at least in New York. No case recognised as 
typhoid occurred in a child under two years of age during my eight years' 
service in the New York Infant Asylum, where about 10,000 eases of acute 
illness were treated and over 700 autopsies made. No case has been i 
nised as typhoid, either in the wards or the post-mortem room of the 
York Foundling Hospital during the past twenty- five years. Typhoid 
65 



1010 THE SPECIFIC INFECTIOUS DISEASES. 

has been soon by MurchisoD at six months and by Ogle at four and a half 
months, the diagnosis being in both Instances confirmed by autopsy; also 
by Griffith at sovon months and by Taylor at eight months, with fairly 
typical symptoms. It is during epidemics that most of the infantile cases 
are Been; sporadic instances of infantile typhoid should always be re- 
garded with suspicion, and T believe that most cases so diagnosticated are 
questionable. Even in epidemics it is surprising that so few infants are 
attacked. In that of Montclair, X. J., in 1894, of 115 cases, only 3 were 
under two years; in that of Stamford, Conn., in 1895, of 406 cases only 
4 were under two years. 

Typhoid in childhood is by no means rare, but it is not until after 
the fifth year that it can be said to occur frequently. The following 
figures, embracing groups of cases reported by eight writers, represent the 
relative frequency with which the disease is seen at the different ages: 
Of 970 cases, eight per cent occurred under five years, forty-two per cent 
between five and ten years, and fifty per cent between, ten and fifteen 
years. 

Typhoid fever is almost invariably contracted by drinking water or 
milk which contains the germs of the disease. The infrequency of 
typhoid in infants is explained, in part at least, by the fact that most 
of the water and a large part of the milk taken are previously boiled, 
or heated in some manner. 

Lesions. — Typhoid in young children is so seldom fatal that oppor- 
tunities for a study of the lesions have been limited. In a general way 
they resemble those of adults except in severity. In a considerable num- 
ber of the cases the pathological process in the intestines does not go on 
to ulceration; and when ulcers form they are seldom large or deep, and 
perforation is very rare. Montmollin gives the following facts concern- 
ing twenty-three autopsies, most of them, however, being in children 
over eight years old : ulcers were present in seventeen cases ; they were 
situated in the lower ileum in sixteen, and in ten they were only there; 
in the ascending colon in nine, and only there in one case; perforation 
occurred in three cases, in every instance in the lower ileum. Autopsies 
made upon infants may show even less severe intestinal lesions than those 
mentioned. In fact, some cases in which the clinical diagnosis was 
beyond question, have shown only moderate redness and swelling of 
Peyer's patches, the solitary follicles and the mesenteric lymph nodes — 
lesions which are exceedingly frequent in cases of simple diarrhoea. In a 
doubtful case such post-mortem findings do not establish the diagnosis 
of typhoid. Indeed, they prove nothing unless cultures from the intes- 
tinal contents, the mesenteric glands, or other organs, show the typhoid 
bacillus. Enlargement of the spleen is practically constant. The de- 
generative changes in the heart, the kidneys, and the liver are much 
less frequent and generally less severe than in adults. 



TYIMIOII) FEVER. 101 I 

Symptoms. — The peculiar features of typhoid in early life are 
only in children under ten years old ; for after this tunc the disease decs 
not differ essentially from the adult type. In brief, the typhoid of early 
childhood may be described as a fever characterised more often by nerv- 
ous symptoms than by intestinal symptoms. 

Onset. — A sudden onset with well-marked symptoms — fever, pros- 
tration, vomiting, etc. — is not uncommon; in fact, it is quite as fre- 
quently seen as the insidious beginning, with lassitude, headache, coaled 
tongue, anorexia, and gradual rise in temperature. In cases developing 
abruptly it often appears as if an acute indigestion had been tin; means 
of precipitating the attack. The most frequent initial symptom is vomit- 
ing; a chill is rare. Epistaxis occurs as an early symptom rather less 
frequently than in adults. 

Condition of the Bowels. — There is no constant relation between the 
severity of the intestinal lesions and the condition of the bowels. Tak- 
ing large groups of cases together, diarrhoea is present iD about half the 
total number. It is rarely profuse, from two to four discharges a day 
being the average. The appearance of the stools is seldom character- 
istic; they are usually thin and fluid, often containing mucus. Consti- 
pation may be present at the beginning only,- or throughout the attack. 
Tympanites is generally moderate, and is often entirely absent; it usu- 
ally accompanies constipation. Marked iliac tenderness and gurgling 
are infrequent. 

Spleen. — By the end of the first week this is almost invariably found 
to be enlarged to a sufficient degree to be recognised by palpation. Usu- 
ally the spleen extends but an inch or an inch and a half below the ribs, 
but at times it may be three inches or more; persistent enlargement 
always indicates that the disease is not at an end even though the tem- 
perature has reached the normal, and a relapse should be expected. 

Eruption. — It is the experience of nearly all who have seen much of 
typhoid in children that the eruption is less constant, less abundant, 
and less characteristic than in adults. The typical eruption consists o( 
small, scattered, rose-coloured spots, which appear chiefly or solely upon 
the abdomen at the beginning of the second week. They come in suc- 
cessive crops, each one of which generally lasts three days, the whole 
duration of the eruption being about ten days. 

Prostration, Emaciation, etc. — As a rule the prostration is quite suffi- 
cient to keep a child in bed after the first few days. The general weak- 
ness after this time is in direct proportion to the height of the tempera- 
ture. Loss of flesh is steady and usually marked; and in a prolonged 
attack there may be extreme emaciation. 

Temperature. — In the cases with a gradual onset, the typical tem- 
perature curve is one which rises steadily for from two to seven days, 
fluctuates within the limits of one to three degrees during the second 



1012 



THE SPECIFIC INFECTIOUS DISEASES. 



week, and steadily declines during the third week, reaching the normal 
on the average at the end of the third week. In cases with an abrupt 
onset, the temperature rises at once to from 102.5° to 105° F., but sub- 
sequently may run the same course as in the first group. 

The following are the most important variations from the tempera- 
ture curve of adults : The initial rise is much more frequently rapid ; 

during the second week the 
remittent character is less 
marked, this probably de- 
pending upon the fact that 
ulceration is less frequent 
and less extensive ; the aver- 
age duration is shorter. In 
young children the propor- 
tion of cases in which the 
fever lasts only from eight 
to fourteen days is quite 
large (Fig. 200). After 
the age of ten years the 
type of the fever is much 
like that seen in adults. 
The maximum temperature 
in the mild cases is 103° or 104° F. ; in the severe ones it often reaches 
105° or 106° F., but rarely goes above this point. The range is usually 
higher than in adult cases of the same severity. At the beginning of 
convalescence a subnormal temperature is very frequent, and by many 
writers is considered to be the rule. A secondary rise is most frequently 
due to errors in diet, but may occur from the development of complica- 
tions. A sudden fall indicates either perforation or intestinal haemorrhage. 



DAY 

104° 
103° 

= 108° 

z 

a 101° 

I 

< o 

"• 100 


1 


i 


o 


i 


6 


G 


7 


8 


9 


10 


11 


12 


13 


































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IS 


A 






A 


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1 


V 


1 I 




i 


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A 














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V 


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99° 
98° 
97* 


1 




V 


V 








V 




\ 




























u 


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s, 



Fig. 200. — Typhoid Fever of Short Duration 
in a Child Thirteen Months Old. Spleen 
enlarged; eruption typical; no diarrhoea and only- 
moderate abdominal distention. There were two 
other cases in the family, all being due to the 
same cause — infected milk. (After Northrup.) 



DAY 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 -35 36 37 38 39 40 41 42 43 


K 
III 

X 
Z 
111 

at 

X 

z 


ii>i<iii<iicii>!>iii iiiuiK lam i< it ii iiiioimi niuti) i>i< ii immmiii i 




101° A ^ * l\ / 


o^A2/v^rr ^-/Zfv -, 


5 r * ,_^ .xr t ik_i 


J V J ft *rt \ jUi 


2° X tv- v^ftf 


Z° A c f v A~ ^ ttt^-, 


1° ^3 X-l v f ^7t-=^ 


J t w fs R 


N 



Fig. 201. — Typhoid Fever with Relapse. Child two and a half years old; early tem- 
perature high and symptoms typical; natural fall on fourteenth day; rise on seven- 
teenth day apparently due to otitis ; relapse on twenty-fourth day, with fresh eruption 
and return of splenic swelling which had disappeared. Temperature was subnormal 
at the end both of primary and secondary fever. 

Relapses were present in 8.4 per cent of 533 cases collected by Morse. 
They follow about the same course as in adults (Fig. 201). 



TYPHOID FEVER. 1013 

Nervous Symptoms. — As a rule, these are more; prominent in Bevere 
cases than the intestinal symptoms, and are directly proportionate to the 
height of the temperature. The extreme nervous symptoms belonging 
to the typhoid state in adults are rare in childhood, except in patients 
over ten years old. Headache and mild delirium at night are very fre- 
quent, the former being seen in the majority of cases. Young children 
are usually dull, apathetic, and often in a state of semi-stupor. Oc- 
casionally the disease may closely simulate meningitis. The nervous 
symptoms are usually most severe in the second, or early in the third 
week, and subside as the temperature declines. 

Pulse. — This is increased in frequency, but not to the degree that 
is seen in most diseases of childhood with a similar elevation of temper- 
ature. The force and rhythm of the pulse are usually good, irregularity 
and dicrotism being rare in children as compared with adults. 

Urine. — A small amount of albumin is found in the urine of most 
of the severe cases at the height of the disease, and is due to acute renal 
degeneration; but a marked degree of nephritis is infrequent. In from 
one-fourth to one-third of the cases typhoid bacilli are found in the 
urine, generally in pure culture. They usually appear in the latter part 
of the disease, the second or third week, and may continue for months 
or even years. They are sometimes accompanied by evidence of cystitis 
or nephritis. Their number is in some cases so large as to render the 
urine turbid; in others they give no indication of their presence. Ehr- 
liclr's diazo reaction is usually present at the height of the fever. 

Blood. — The characteristic blood picture in typhoid is a low leucocyte 
count, generally under 10,000, accompanied usually by a slightly increased 
proportion of lymphocytes. Blood cultures, with great uniformit} r , show 
the bacilli even in the first week of the disease. 

Intestinal Haemorrhage. — Of 946 collected cases, mainly from hospital 
reports, intestinal haemorrhage occurred in thirty, or about three per 
cent; the majority of these were in children over ten years old. Of 
twenty-four collected cases of haemorrhage in children, ten terminated 
fatally. The youngest case of this nature which has come under my own 
notice was in a child of four and a half years. 

Intestinal Perforation. — This is even more rare than haemorrhage. 
In 1,028 collected cases, this accident occurred but twelve times, or in 
1.1 per cent. Perforation is indicated by a sudden fall in the tem- 
perature, with collapse; usually there is vomiting and the rapid devel- 
opment of tympanites. 

Complications and Sequelae. — The complications of typhoid in early 
life are infrequent and usually mild. Bronchitis is present in most of 
the severe cases. Pneumonia has been noted in nine per cent of the cases 
reported by various authors. Both serous and purulent effusions into 
the chest are occasionally seen, and sometimes abscess of the lung. 



1014 THE SPECIFIC INFECTIOUS DISEASES. 

Complications referable to the nervous system are not very frequent, 
but are of much interest. Meningitis is extremely rare. Morse lias 
collected twenty-one cases of aphasia, in two of which it was clearly due 
to embolism; in the remainder, however, it apparently was not dependent 
upon any organic lesion. In two-thirds of the cases it came on during 
convalescence, and in nearly all complete recovery occurred after an 
average duration of three weeks. Aphasia usually followed a severe type 
of the disease, and in most of the cases was not accompanied by any other 
paralysis or by mental disturbance. Insanity is a rare sequel of typhoid 
in children, the usual type being acute mania. Adams (Washington) 
has reported two examples of this, both terminating in recovery. Chorea 
is seen rather oftener than after the other infectious diseases. 

Otitis is not an infrequent complication, occurring much oftener than 
in adults. It is principally seen in young children and during the cold 
season. Among the less frequent complications may be mentioned : paro- 
titis, which is usually suppurative and is seen in septic cases; abscess 
of the liver, examples of which have been reported by Bokai, Asch, and 
others; gangrenous inflammation of the mouth or genitals; pericarditis, 
endocarditis, and peritonitis, suppurative inflammations of joints, mul- 
tiple abscesses and furunculosis. Tuberculosis of the lungs or bones not 
infrequently follows typhoid. 

Diagnosis. — The diagnostic symptoms of typhoid are the Widal blood 
reaction, the discovery of the bacilli in the blood, urine or f aeces, the erup- 
tion, the course of the temperature, the enlargement of the spleen and the 
abdominal symptoms — diarrhoea, tympanites, intestinal haemorrhage, and 
perforation. 

The Widal reaction is present at some period in from ninety-five to 
ninety-eight per cent of the cases, and thus becomes the most valuable 
single symptom for diagnosis. It is seldom obtained before the seventh 
day and frequently not until the tenth; it may not be present until 
convalescence or a relapse. Eepeated tests should always be made if 
the first reaction is negative or doubtful; and the tests should be made 
by an experienced pathologist. The reaction is therefore of much less 
value for an early than for an exact diagnosis. A positive reaction may 
be present if the patient has previously had typhoid, something much less 
likely to be the case with children than with adults ; in rare instances it 
has been obtained in other diseases or in health when no history of 
previous typhoid existed. Both these conditions, however, are very ex- 
ceptional, and a positive reaction may as a rule be taken to establish 
the diagnosis. 

Typhoid bacilli, according to the observations of Park, may be 
demonstrated in the stools by culture in a large proportion of the cases. 
They are found in the urine, usually in the latter part of the disease, 
in about one-third the cases. Their discovery in either of these discharges 



TYPHOID FEVER. 1015 

is conclusive evidence of previous or existing typhoid. An examination 
of both urine and faeces should, if possible, be made in all doubtful 

The course of the temperature is an important aid to diagnosis, but 
alone is not to be depended upon. The characteristic feature is a fever 
which continues for two, three, or four weeks, and subsides spontaneously. 
The variations from the adult type have already been mentioned, also 
the frequency of the eruption, the enlargement of the spleen, and the 
abdominal symptoms. We are not warranted, I think, in making the 
diagnosis of typhoid, if repeated tests fail to show the Widal reaction or 
if the eruption and splenic enlargement are absent, and no bacilli can 
be demonstrated in the discharges, no matter what the course of the 
temperature may be. 

One should hesitate to make the diagnosis of typhoid in a child 
under two years old, unless the disease is epidemic. The great majority 
of sporadic cases reported as occurring in infancy are probably not 
typhoid. After the fifth year the disease is more frequent, and its symp- 
toms in general resemble those of adults, except in severity. 

A differential diagnosis is to be made from malarial fever, ileo-colitis, 
meningitis, tuberculosis, and from other ill-defined continuous fevers of 
unknown origin. From malarial fever the diagnosis is to be made by 
the temperature curve, the organisms in the blood, and the effect of 
quinine. In most of the cases of malaria the temperature will be found 
to touch the normal at some time in the twenty-four hours. The admin- 
istration of full doses of quinine is a diagnostic test of much practical 
importance; an irregular or remittent fever which yields promptly to 
quinine is most certainly not typhoid. 

Ileo-colitis and typhoid fever are not often confounded. The former 
is chiefly seen in the first three years of life, a time when typhoid is rare. 
The intestinal symptoms of ileo-colitis are marked even though the tem- 
perature is not high, and they are altogether more severe than is usual 
in typhoid; while enlargement of the spleen, tympanites, and the erup- 
tion are not present. 

The cerebral symptoms of typhoid may be difficult to distinguish from 
meningitis, unless one has watched their development. Irregular respira- 
tion, a slow, irregular pulse, localised paralysis and complete coma are 
seldom, if ever, seen in typhoid, and a retracted abdomen very rarely, 
while the enlarged spleen and the peculiar eruption are not seen in men- 
ingitis. In typhoid with pronounced nervous symptoms the temperature 
is usually higher than in meningitis. 

General tuberculosis very often resembles typhoid so closely that a 
differential diagnosis is almost impossible until local signs of tuber- 
culosis have appeared, usually in the lungs. 

Prognosis.— Of 2,623 cases in children, collected from the reports of 
twelve different writers, the mortality was 5 .4 per cent. These are, how- 



101 1) THE SPECIFIC INFECTIOUS DISEASES. 

ever, almost all taken from hospital reports, where as a rule the mildest 
cases are not brought for treatment. The mortality of the disease in 
children over throe years old probably does not exceed three or four per 
cent. Heath seldom occurs from the disease itself, but usually from some 
accident or complication, the most frequent being pneumonia and intes- 
tinal haemorrhage or perforation. Griffith's collection of cases occurring 
in infancy indicates a much higher mortality for this period. The death- 
rate for the first year reached nearly fifty per cent. 

Treatment. — The usually low mortality of this disease shows how 
successful all methods of treatment are likely to be considered. In the 
great majority of cases very little active treatment is required. Every 
patient with typhoid should be put to bed and kept there during the 
febrile period, and a few days beyond it, no matter how mild the attack 
may be. The diet should consist of sterilised milk or animal broths, 
cereal gruels and very soft eggs. These articles should be given regularly 
every three hours, but not pushed beyond the desire of the patient. Milk 
may be diluted or partially peptonised, and kumyss or matzoon may be 
substituted for it if the stomach is irritable. Plenty of water should be 
given. Solid food should not be allowed until the temperature is normal. 

Both the urine and faeces should be immediately and thoroughly dis- 
infected by a solution of carbolic 1 : 20. If the movements are in a 
chamber or a bed-pan they should be covered with this solution for at 
least six hours before they are thrown into the water-closet. If napkins 
or diapers are used, they should be soaked in some effective antiseptic 
solution for twelve hours and then thoroughly boiled. Sheets stained 
by discharges should be treated in the same way, and all bed-linen should 
be boiled for two hours apart from the washing of the family. The 
efficiency of hexamethylenamine (urotropin) in removing typhoid bacilli 
from the urine seems now to be well established. It should be given at 
the close of the attack in doses of three to five grains, three times a day, 
and continued for a week or ten days. 

Diarrhoea calls for treatment only when the movements exceed four 
or five in twenty-four hours. If no more than this number are present, 
they should not be interfered with. Opium and bismuth are undoubt- 
edly the best means for controlling excessive diarrhoea, but care should 
be taken that they are not pushed to the degree of inducing con- 
stipation. 

Constipation early in the disease may be relieved by calomel, followed 
by the salines, or castor oil, but all active purgation should be avoided. 
Later in the disease daily irrigation of the colon with tepid water is 
better than anything else. On the whole, constipation is more trouble- 
some to overcome than diarrhoea. 

Tympanites is rarely severe enough to require treatment; it may be 
relieved by turpentine stupes, by a glycerin suppository, or a small 



TUBERCULOSIS. 1017 

glycerin injection (one teaspoonful of glycerin to two ounces of wafer), 
or, better still, by the use of the rectal tube. 

Whenever the temperature remains above 104° P., antipyretic meas- 
ures are indicated. In mild cases cold or tepid sponging is generally 
sufficient. In those which do not yield to such measures, baths may be 
employed. Not all children bear baths well, and considerable discretion 
should be used in employing them. One should he guided quite as much 
by the effect upon the pulse and the nervous system as by the tempera- 
ture. The best method is usually the graduated bath; the child is placed 
in the tub with the water at a temperature of 95° or 100° F. ; this is 
gradually lowered to 95°, 90°, or even 85° F., but seldom lower. The 
body should be actively rubbed while the child is in the bath, to prevent 
shock and cardiac depression. The cold pack may be substituted for the 
bath where circumstances make the latter impracticable. The bath or 
pack should be repeated -in an average case in from three to six hours. 

The milder nervous symptoms — headache, restlessness, sleeplessness, 
etc. — may be relieved by an occasional dose of phenacetine, either alone 
or in combination with the bromides, or by cold or tepid sponging; the 
more severe ones usually occur with high temperature, and are best con- 
trolled by the cold bath. 

Stimulants in most of the cases are not called for. They are to be 
given according to the indications afforded by the pulse, the first sound 
of the heart, and the child's general condition. They are seldom needed 
earlier than the end of the second week. Intestinal haemorrhage calls 
for absolute quiet, morphine hypodermically, and an ice-coil to the ab- 
domen, nothing being given by mouth except stimulants, turpentine, and 
possibly opium. Intestinal perforation is successfully treated only by 
early laparotomy. 

CHAPTER X. 
TUBERCULOSIS. 

Tuberculosis is an infectious communicable disease, due to the 
bacillus tuberculosis of Koch. It may be local or general, and may in- 
volve any organ and almost any structure in the body. 

Etiology. — Age and Frequency. — No age is exempt from tuberculosis. 
It was formerly believed that the disease was rare in infancy, but recent 
observations have shown the opposite to be the case. 

Statistics taken chiefly from three New York institutions whore only 
infants and young children are received give the following figures Eor 
382 cases of tuberculosis, the diagnosis being confirmed by autopsy in 
nearly every instance: In the first year there were 160 cases, and of 
these 67 were under six months, 10 of which were under three months 



1018 



THE SPECIFIC INFECTIOUS DISEASES. 



of ago. The frequency of tuberculosis appears to increase steadily as 
age advances, as shown by the following table, in which results found 
at autopsy are compared with those obtained by means of v. Pirquet's 
skin reaction. Both scries are from Vienna. 



Age. 



Under 3 months . 
3 to 6 

6 to 12 " . 

2d year 

3d and 4th years 
5th and 6th years 

7 to 10 years .... 
11 to 14 " .... 
Over 14 " .... 



I. Hamburger: Autopsies. 



No. of 
Cases. 



105 

73 

140 

179 

175 

67 

65 

44 



848 



Percentage of 
Tuberculosis. 



4 per cent 
18 
23 
40 
60 
56 
63 
70 



40 per cent 



II. v. Pirquet: Skin Testa. 



No. of 
Tests. 



147 

64 

67 

88 

127 

101 

182 

100 

112 



988 



Percentage of 
Reactions. 



per 

5 
16 
24 
37 
53 
57 
68 
90 



cent 



41 per cent 



From the facts at hand it would seem that the percentage of children 
with tuberculosis is much greater in Europe than in this country. The 
following table gives figures for three institutions with which I am 
connected in New York, as compared with data taken from Vienna and 
Munich. 

Frequency of Tuberculosis as Shown by Autopsies. 



Institution. 


Age of Patients. 


No. of 
Autopsies 


No.showing 
Tuber- 
culosis. 


Percentage of 
Tuberculosis. 


N. Y. Infant Asylum. . 

Babies' Hospital 

N.Y. Foundling Hosp. . 

Miiller — Munich 

Hamburger — Vienna. . . 

It a 


Nearly all under 23^ years. 

" 3 

Children of all ages 

All ages up to 14 years .... 
( Including only children \ 
\ of 2 years and under . ) 


726 

1,000 

1,000 

500 

848 

497 


56 

168 
136 
200 
335 

120 


8.0 per cent 
16.8 " 
13.6 " 
40.0 " 
40.0 " 

24.4 " 



These percentages are not to be taken to represent the occurrence 
of tuberculosis in the community generally, but only its frequency in 
the class which furnishes hospital and institution inmates. Nor are 
these figures to be interpreted as showing the percentage of active tuber- 
culosis. In the cases showing tuberculosis at autopsy nearly one-third 
of the number died from other diseases, tuberculosis being latent and 
its existence being discovered only post mortem. Likewise in nearly 
one-fifth the cases giving positive skin reactions there were no evidences 
of active tuberculosis. 

Predisposing Causes. — These include all the conditions which bring 
about a diminished resistance of the body to tuberculous infection. This 



TUBERCULOSIS. 1019 

susceptibility may bo inherited, as when parents have Buffered from tu- 
berculosis or other constitutional disease, syphilis, alcoholism, etc. It 
may be due to the fact that children have been reared in crowded city 
tenements, in institutions, or under other unfavourable surroundings. 
A local predisposition may be afforded by any pathological condition 
of the organs or mucous membranes exposed to infection. Thus, adenoid 
growths of the pharynx or large tonsils may favour the development 
of cervical adenitis, and frequent attacks of bronchitis may precede pul- 
monary tuberculosis. Certain infectious diseases, particularly measles, 
whooping-cough, and influenza, greatly increase a child's susceptibility 
to tuberculosis, and these may also cause a latent tuberculosis to develop 
into an active process. General or pulmonary tuberculosis is therefore 
often seen as a sequel to the diseases mentioned, the latent focus for 
which has been tuberculous bronchial glands. 

Modes of Infection. — Intra-uterine infection, although rare, has been 
established by the report of at least seven complete and well-authenti- 
cated cases. Tuberculosis of the placenta is more frequent. In most of 
the cases of congenital tuberculosis the mother has been suffering from 
the disease in an advanced form, and the child is either still-born or 
dies soon after birth. Besides tuberculosis of the placenta, tubercle 
bacilli are found in the organs of the child, and, when life is prolonged, 
there are generalised lesions showing infection through the blood. 
Cheesy nodules have been observed in the umbilical cord. Intra-uterine 
infection is highly probable in many of the children born of tuberculous 
mothers, who develop the disease during the first few months of life, al- 
though they may show no evidence of it at birth. Among my own cases 
there was one only twenty days old. The child was born prematurely of a 
mother suffering from advanced tuberculosis. Besides other lesions, the 
autopsy showed, in the case of the mother, tuberculosis of the endo- 
metrium. 

Tuberculosis may be communicated by direct inoculation, as in the 
case of a bite from a person suffering from the disease, several instances 
of which are on record. The rite of circumcision performed by a rabbi 
suffering from tuberculosis is also known to have caused the disease. 
One of the most striking instances of direct infection is that reported by 
Reich. 1 In a town of about 1,300 inhabitants, the obstetric practice was 
divided between two midwives. Within fourteen months no less than 
ten infants, who had been delivered by one of these women, died of 
tuberculous meningitis. In none of these families was there a history 
of tuberculosis. This midwife was found to be suffering from pulmonary 
tuberculosis, and died from that disease. It was her custom to remove 
the mucus from the mouth of the newly-born infants by direct mouth- 

1 Berliner klinische Wochenschrift, No. 37, 1878 



1020 THE SPECIFIC INFECTIOUS DISEASES. 

to-moutb aspiration, and theD to establish respiration by blowing into 
the nose. In the practice of the other midwife, who was healthy, no 
eases of tuberculosis occurred, although she treated the newly-born in- 
fants in the same fashion. 

I believe that altogether the most frequent means by which children 
acquire tuberculosis is from association with persons suffering from pul- 
monary tuberculosis. Some of these are persons in the active stage of 
the disease ; many are supposed to have been cured ; in others the disease 
has not yet developed so as to be recognised. Bacilli may be directly 
conveyed by kissing. Dried sputum containing bacilli may become a 
part of the dust of the room ; it may be inhaled or it may be introduced 
into the mouths of children by hands, toys, or other objects. The source 
of infection is usually one or other parent or some member of the house- 
hold — a nurse, caretaker, servant, or a frequent visitor. A history of 
such exposure was* definitely traced in forty-four per cent of 101 con- 
secutive cases of tuberculosis in young children which were investigated 
at the Babies' Hospital. These figures do not represent the proportion 
of the cases in which the disease is so contracted. I believe there is a 
very much larger number in which this connection can not be traced. 
Doubtless exposure antedates symptoms by a number of weeks, at least, 
often by several months. In instances where it could be pretty accu- 
rately ascertained, the interval between exposure and development of 
symptoms was from four to twelve weeks. 

Infection may take place from beds, rooms, sleeping cars, or any 
apartments previously occupied by tuberculous patients; from dishes or 
spoons, from glasses at public drinking places; also from the milk of 
tuberculous cows x or from meat. My own observations lead me to the 
conclusion that only a very small proportion of children contract tuber- 
culosis in these indirect ways. Infection through milk I believe to be 
relatively rare. (See chapter upon Milk.) Unless the disease in an 
animal is far advanced or the udder is involved, the number of bacilli 



1 In this connection the following incident is interesting as bearing upon the other 
side of the question: Near a large American city was a fancy stock farm of registered 
Jersey cows, which supplied milk for table use and infant feeding to a large number 
of families in the wealthiest part of the city, for a period of over ten years. At the 
end of that time the tuberculin test was used for the first time, and 45 per cent of 
these cows were found to be tuberculous, and were killed by order of the State Board 
of Health. The diagnosis was confirmed by autopsies upon the animals in every 
instance. An investigation was instituted among the children who had been fed 
upon this milk, but in only one case of many hundreds could it be learned that tuber- 
culosis had developed, and in this instance it was by no means established that the 
milk had been the source of infection. It should be stated that this was before the 
days of sterilising milk for infant feeding. Besides the families who took the milk 
in the manner mentioned, the employees at the farm were accustomed to drink the 
skimmed milk in large quantities daily as a beverage in the place of water. Many of 
them continued to do this for years, and yet not one of them developed tuberculosis. 



TUBERCULOSIS. [02] 

present in the milk of a tuberculous cow is small and the chani 
infecting a child are slight. Those which enter may be destroyed in the 
stomach or pass through the intestinal tract without doing harm. Bacilli 
entering through the respiratory tract unfortunately have no such read) 
means of exit. Infection from the meat of tuberculous animals is a pos- 
sibility, but hardly more. Bollinger's experiments in feeding animals 
with the expressed juice of such meat gave negative results. 

Types of Bacilli. — Important information in regard to the source of 
infection is obtained from a study of the type of organism present in the 
different varieties of tuberculosis. Of 137 cases of tuberculosis in chil- 
dren investigated by Park and Krumwiede in the Research Laboratory 
of the New York Health Department the following results were ob- 
tained : The human type was found in 107 cases ; of which 13 were pul- 
monary; 29, glandular; 2, abdominal; 33, meningeal; 16 in bones and 
joints; 1, genito-urinary ; and 13 were generalised. The bovine type 
was found in 30 cases; of which none were pulmonary; 20, glandular; 
5, abdominal; 1, meningeal; none, bones and joints alone; 4, generalised. 

Paths of Infection of the Tubercle Bacillus. — Tubercle bacilli may 
gain entrance to the body through the respiratory or the alimentary 
tract or the skin, the last, however, being so rare that it needs only to 
be mentioned. In infancy and early childhood, infection I believe to be 
most frequent through the respiratory tract. The situation of the pri- 
mary lesions strongly supports this view. Bacilli taken in with the 
inspired air may lodge upon the adenoid tissue of the naso-pharynx and 
enter the body through the blood or the lymph stream. Such infection 
is favoured by pathological conditions of these structures. Bacilli which 
pass the upper respiratory tract may not be arrested until the smaller 
bronchi are reached. Both clinical experience and animal experiments 
indicate that the bacilli may pass through a mucous membrane without 
inducing in it a tuberculous disease, but that penetration is much easier 
if the mucous membrane is the seat of a catarrhal inflammation, or if 
the epithelium has been injured. The bacilli are usually taken up by 
the lymphatics from the surface of the mucous membrane upon which 
they have lodged, and are carried to the nearest lymph nodes, where 
they may excite a tuberculous inflammation, but where they may be 
permanently arrested. The great majority of children who suffer from 
tuberculosis of the cervical lymph nodes escape general tuberculous in- 
fection. 

In autopsies both upon children and adults dying from various non- 
tuberculous diseases it is not infrequent to find tuberculosis limited to 
the bronchial lymph nodes. 

Arriving at the lymph node, the bacilli light up a tuberculous in- 
flammation of varying degrees of intensity, depending upon their number 
and upon local conditions. This inflammation may pass through the 



1022 THE SPECIFIC INFECTIOUS DISEASES. 

usual changes o\' tuberculous glands — congestion, swelling, cell prolifera- 
tion, and caseation ; or the process may be arrested at any point, and the 
products of inflammation become encapsulated by a proliferation of 
fibrous tissue, in which condition they may remain latent in the body 
for an indefinite number of years — possibly for a lifetime. This occurs 
in many children, and is consistent with every outward sign of health; 
but it is a smouldering ember which at any time may be fanned into 
flame under the stimulus of an inflammation excited b}' some other 
cause. 

In infants and young children there is a strong tendency for the 
bacilli to lodge first in the bronchial lymph nodes, probably on account 
of the favourable conditions for entrance existing in the bronchi and 
lungs. In those who are delicate and have but little resistance, the 
process in the lymph nodes is likely to go on to caseation and softening, 
and, secondary to this process in the glands, the lung may become in- 
fected. The manner of the extension of the disease to the lung is not 
always easy to trace; but in many instances it has been shown to be the 
result of the softening of one of these small tuberculous ljrmph nodes, 
which then ulcerates through the wall of one of the small bronchi or a 
blood-vessel, in this way distributing its bacilli through the lung. 

Although this is the course usually taken by bacilli when they are 
inhaled, it is not always the case. Lesions in the lungs are occasionally 
found where the lymph nodes are not involved ; and there are other cases 
in which advanced changes exist in the lung, while only the earlier ones 
are seen in the tymph nodes. In these cases, which perhaps are to be 
considered as exceptional, the tuberculous process probably begins in 
the walls of the small bronchi, the alveoli, or in the connective-tissue 
septa. 

For bacilli which may find their way into the mouth the tonsils may 
be a portal of entry. Those which pass to the stomach rarely cause 
lesions of the gastric mucous membrane, or through it reach the lym- 
phatic circulation. In the intestines, however, more favourable condi- 
tions exist. It is possible for the bacilli to reach the mesenteric lyruph 
nodes without causing a lesion of the intestinal mucous membrane, and 
experiments upon animals have shown that from the intestine they may 
even reach the bronchial lymph nodes; but in the human subject I be- 
lieve both to be exceedingly rare. By careful search I have seldom 
failed to find intestinal ulceration when the mesenteric lymph nodes 
were manifestly tuberculous. 

Lesions. — In the following table are given the lesions found in 255 
autopsies, of which I have notes. These represent the lesions of infancy 
and early childhood, seventy per cent of these children being two years 
old or under. For comparison there are given statistics of 131 autopsies 
from the Pendlebury Hospital, Manchester, England. Few of the chil- 



TUBERCULOSIS. 



1023 



dren in this series were under three years old. The greater frequency 
of abdominal tuberculosis, especially tuberculous peritonitis, will be 
noted. This difference obtains in nearly all the English statistics of the 



Frequency of the Different Visceral Lesions of Tuberculosis. 



Organs. 



Lungs 

Pleura 

Bronchial lymph nodes . 

Brain 

Liver 

Spleen 

Kidneys 

Stomach 

Intestines 

Mesenteric lymph nodes 

Peritonaeum 

Pericardium 

Endocardium 

Thymus 

Suprarenal capsules .... 
Pancreas 



Personal cases; 

255 autopsies (chiefly under 

three years). 



235 

93 

208 

85 

178 

191 

88 

7 

110 

118 

22 

10 

1 

5 

4 

4 



92.1 per 

36.5 . 

81.5 

33.3 

69.8 

74.9 

30.6 

2.7 
43.1 
52.4 

8.6 

3.9 

0.4 

1.9 

1.5 

1.5 



cent 



Pendlebury Hospital Reports; 

131 autopsies (chiefly over 

three years). 



122 

100 

91 

60 

86 

76 

54 

1 

65 

77 

37 

4 



93.0 per cent 

76.0 

70.0 

46.0 

65.0 

58.0 

41.0 

0.8 
50.0 
59.0 
28.0 

3.0 



1.6 per cent 



The Varieties of Tuberculosis seen at Different Ages. — During the 
first two years of life, tuberculosis most frequently involves the lungs 
and bronchial lymph nodes. It is the meningeal or pulmonary process 
which most often is the cause of death. Death from other forms of 
tuberculosis is rare at this time of life. Of 232 deaths from tuberculosis 
in the first three years of life, meningitis was the cause in 93, tuberculous 
peritonitis in only one, and haemorrhage from a tuberculous ulcer of the 
intestine in one. 

After the second year, tuberculosis of the bones, cervical and mesen- 
teric lymph nodes, peritonaeum, and intestines becomes more frequent, 
and may occur as the principal lesion, although at autopsy the lungs 
are usually involved to some degree. 

Pulmonary Lesions. — As compared with that of adults, the pulmo- 
nary tuberculosis of young children is more widely diffused, and the pre- 
dominance of cases in which the lesion is in the upper lobes is less 
marked, though it still exists. In those who have passed the sixth or 
seventh year, the pathological processes resemble those of adult life. Al- 
though localised tuberculous processes are frequently met with in pa- 
tients dying from other diseases, those who die from tuberculosis usually 
show wide-spread lesions of the lungs. 

1. Miliary Tuberculosis of the Lungs. — In nearly every case of pulmo- 
nary tuberculosis, miliary tubercles are found in some part of the lung, 
usually upon the surface and in the vicinity of some older process. Occa- 



1024 THE SPECIFIC INFECTIOUS DISEASES. 

sionallv. they are distributed throughout nearly the whole of both lungs. 
In some places the lung, with the exception of these numerous gray 
granulations, appears quite normal; in others it is congested, and shows 
between the tubercles the lesions of simple broncho-pneumonia in its 
various stages. There is also an acute bronchitis of the middle-sized 
and smaller bronchi. The microscope shows that the tubercles usually 
develop in the walls of the small bronchi or the blood-vessels. In their 
gross appearance, 'the lungs in these cases resemble those in ordinary 
acute broncho-pneumonia, with the exception that everywhere upon the 
surface and throughout the substance of the lung are seen the small 
gray granulations, and in most cases some small yellow tuberculous 
nodules. The pleura is usually normal except for the presence of the 
tubercles. This form of the disease represents the rapid dissemination 
of tubercle bacilli throughout the lungs, the miliary tubercles being the 
result of the inflammation excited by their presence. 

2. Tuberculous Broncho-pneumonia. — This is the most frequent and 
the most characteristic form of tuberculosis in infants and young chil- 
dren, and it is the one which at this age usually causes death. In this 
form of the disease there are produced in the lung caseous nodules, or 
larger caseous areas, some of which have usually undergone softening by 
the time the case comes to autopsy. The process generally runs a some- 
what subacute course. With the lesions mentioned there are always 
associated those of simple broncho-pneumonia. 

The pleura is involved in almost every case. There may be simply 
dense connective-tissue adhesions which bind the lung firmly to the chest 
wall, the diaphragm, and the pericardium, or the pleura may be greatly 
thickened and contain caseous deposits. Occasionally empyema is seen, 
but it is almost always sacculated and small. 

Both lungs are usually involved, but one to a much greater degree 
than the other. There are found large areas of consolidation which some- 
times involve an entire lobe, but more often smaller areas are seen in sev- 
eral lobes. These portions of the lung appear much firmer and harder than 
in ordinary pneumonia. The upper lobes are more often affected than 
the lower, and especially that part of the lobe which is near the root 
of the lung, on account of its frequent association with tuberculosis of 
the bronchial glands; the disease very often extends forward from this 
point to the middle lobe of the right, or the corresponding part of the 
left lung. On section the affected part of the lung usually shows many 
caseous nodules varying in size from a pin's head to a walnut, which 
are of a pale yellow colour, and resemble caseous lymph nodes. They 
contain giant cells and are usually filled with bacilli, those which have 
softened containing yellow pus. There is nearly always seen in some 
part of the lung a large caseous area; and not infrequently there may 
be diffuse caseation of almost an entire lobe (Figs. 202, 204). Some- 



TUBERCULOSIS. 



1021 



times no spot of softening is seen even in these large areas, l>ut in many 
cavities are present. 

Softening and excavation represent the final stages of the process 
in tuberculous pneumonia, Softening usually begins in the centre of a 
caseous part, often at several points at the same time. Areas of excava- 
tion large enough to deserve the name of cavities were present in about 




Fig. 202. — Tuberculous Pneumonia. A 
vertical section through the middle of the 
right lung of a child thirteen months old. 
The greater part of the upper lobe is uni- 
formly caseous — a diffuse tuberculous 
pneumonia; near the centre the com- 
mencement of a cavity is seen; below it 
has the appearance of a consolidation from 
simple pneumonia. The part of the lower 
lobe shown is normal. 




Fig. 203. — Cavity from Breaking Down 
of Tuberculous Pneumonia. Another 
view of the same lung, the section being 
made very near the posterior border of the 
lung. The cavity occupies at this point 
nearly the whole of the upper lobe. At 
autopsy this cavity contained numerous 
loose caseous masses, the largest being the 
size of a marble. The lower lobe is nor- 
mal. (For history, see Fig. 20S.) 



half of my autopsies upon tuberculous patients, two years old and under. 
They vary in size from a cherry to a hen's egg, and sometimes a much 
larger one is seen (Fig. 203). They are usually rather deeply seated, 
and are partially or entirely filled with caseous masses or pus, bui very 
seldom perforate the pleura, causing pneumothorax or pyopneumothorax. 
66 



1026 THE SPECIFIC INFECTIOUS DISEASES. 

It is rare in a young child bo find cavities Burrounded by dense fibrous 
walls such as arc soon in older children or in adults; for in infancy the 
process o( softening once begun usually advances steadily until the death 
of the patient. 

The bronchial lymph nodes are in these eases invariably found to be 
tuberculous, and not only those at the root of the lung, but if a dissection 




Fig. 204. — Pulmonary Tuberculosis, Extensive Caseation of Left Lung and 
Bronchial Glands. History. — Coloured child, 2% years old; signs over left lung 
were feeble breathing and flatness, suggesting empyema; twenty- three examinations 
of the sputum made for bacilli, all negative. For the last three and a half weeks, 
temperature showed a regular daily range from 100° to 104° F. 

Autopsy. — Almost complete caseation of left lung; no spots of softening; through- 
out right lung were small tuberculous nodules and miliary tubercles. Bronchial glands 
very large and caseous, but none broken down ; those affected were not only the group 
at the root of the lung but the chain following the main bronchus some distance into the 
lung itself. 

is made, a chain of these tuberculous glands wil 1 be found to follow the 
larger bronchi for some distance into the lung (Fig. 204). Sometimes 
one may be discovered which has softened and ulcerated through into a 
small bronchus. 

Microscopical examination of these cheesy nodules shows that they 
most frequently begin as tuberculous deposits in the walls of the small 
bronchi, either in the mucous membrane, the fibrous coat, or the lymphat- 
ics; sometimes, however, they begin in the walls of a small vein or artery. 
Cell proliferation takes place, separating the coats of the bronchus or 



TUBERCULOSIS. [027 

blood-vessel, and partly or entirely obstructing its lumen. Softening 
may take place and the contents be discharged into the bronchus or blood- 
vessel. About this focus other changes of an inflammatory character 

occur, as a result of which each cheesy nodule is surrounded by a zone 
of simple broncho-pneumonia which tends, in a measure ai least, to limit 
the tuberculous process. The larger caseous areas arc formed by an 
extension of this process to the zone of pneumonia which surrounds it; 
but in its further growth it is still preceded by a simple pneumonia. 
The rapidity with which the lesions advance differs much in the different 
cases; in infants the progress is apt to be continuous until the death of 
the patient; in older children it is usually slower, and interrupted by 
intervals of arrest and even of partial retrogression. 

Xot infrequently one sees in the post-mortem room one or two caseous, 
or less frequently calcareous, nodules encapsulated by firm, organised con- 
nective tissue when a most careful search fails to show any other tuber- 
culous lesion in the lung. If, however, the nodules are widely scattered 
through the lung, such an arrest of the process is not to be expected. 

3. Chronic Pulmonary Tuberculosis, Chronic Phthisis. — In children 
who have passed the seventh or eighth year the pathological process re- 
sembles that seen in adults; but in younger children, and especially in 
infants, nothing corresponding to it is met with. 

At this period the nearest approach to this condition is seen in the 
cases of tuberculous broncho-pneumonia, which run a slow, irregular, 
and somewhat chronic course. The essential features of the process in 
these patients is a chronic interstitial broncho-pneumonia with tuber- 
culous nodules which rarely undergo softening, but usually become en- 
capsulated. 

The gross lesions closely resemble those of simple chronic broncho- 
pneumonia. There are the same generalised pleuritic adhesions and the 
shrunken cicatricial condition of the part of the lung most affected, with 
bronchiectasis, compensatory emphysema, etc. The tuberculous nodules 
are old and for the most part converted into dense fibrous tissue, in the 
centre of which, however, some softened, caseous areas are often seen. 

Bronchial Lymph Nodes (bronchial glands). — The prominence o\' the 
lesions of the lymph nosies is one of the most striking features of tuber- 
culosis in infancy and early childhood. Those which are mosl frequently 
affected are connected with the bronchi. The lymph nodes, to which the 
term "bronchial glands" is generally applied, consist of three groups: 
the first of which surrounds the trachea: the second is situated at the 
bifurcation of the trachea and surrounds the primary bronchi: while the 
third follows the course of the bronchi into the lung, being found, ac- 
cording to anatomists, as far as the fourth division. The anatomical 
relation of the different groups should be borne in mind, since upon them 
the symptoms principally depend. The first group, or the peri-trachea] 



1028 THE SPECIFIC INFECTIOUS DISEASES. 

lymph nodes, are in relation with the superior vena cava, the pulmonary 

artery, the pneumogastric and recurrent laryngeal nerves; the second 
group, at the bifurcation of the trachea, with the oesophagus, pneumo- 
gastric nerve, and aorta; the third group, with the bronchi and the 
branches of the bronchial and pulmonary arteries and veins. 

All the groups are usually involved at the same time, but in varying 
degrees, and in most cases those belonging to one lung to a greater ex- 
tent than the other; in my own cases those of the right side have much 
more often been involved than those of the left. There may be simply 
two or three tumours as large as a hazelnut, or there may be a mass two 
or three inches in diameter, which is made up of ten to twenty of these 
nodes fused together by inflammatory products, completely surrounding 
the trachea and both the large bronchi. It is rare that the individual 
glands are more than an inch in diameter, and most of them are smaller 
than this. A well-marked but not unusual example of this condition is 
shown in Plate XIX. There is usually found a chain of these tuber- 
culous glands following the course of the large bronchi for some distance 
into the lung; sometimes these are almost as large as the external group 
(Fig. 204) ; at other times they are not noticed unless a somewhat care- 
ful dissection is made. The process is not infrequently more advanced 
in these deeply seated glands than in those situated at the root of the 
lung; and lesions here are also more important, as it is very frequently 
through them that the lung becomes involved. 

The pathological changes through which these glands pass as a re- 
sult of tuberculous infection are very similar to those already described 
with reference to the cervical glands. Suppuration is less frequent than 
in the region of the neck, while calcific degeneration is much more so. 
This applies especially to children over three years old. In infancy 
suppuration is not infrequent in the bronchial glands, while at this age 
calcification is extremely rare. Although the process has gone on to 
caseation, these inflammatory products with bacilli may become encapsu- 
lated, and may remain innocuous for an indefinite period. The bacilli 
may die or may exist here, living, for years. At any time the old process' 
may be lighted up, and a more or less rapid dissemination of tubercle 
bacilli take place through the lungs or through the whole body. Latent 
tuberculosis more frequently exists in the bronchial lymph nodes than 
in any other structure in the body. 

Secondary lesions may be produced by these lymph nodes. The pneu- 
mogastric and recurrent laryngeal nerves may be surrounded by one of 
these cheesy masses which causes pressure and irritation. The oesophagus, 
the trachea, or the bronchi may be compressed or opened by ulceration. 
The superior vena cava usually suffers only compression, but this or any 
of the other large vessels may be opened. Ulceration may also take place 
into one of the large or small bronchi or the trachea. If the gland has 



PLATE XIX. 




Tuberculosis of the Tracheo-Broxchial Lymph Nodes. 

From a fairly nourished child, four months old, who was under observation for 
three weeks, with slight fever and a most severe, teasing, dry cough, which was almost 
constant, and upon which no treatment seemed to have the slightest effect. At first 
there were no signs of disease in the lungs; later there were a few coarse scattered 
rales. 

There were small tuberculous deposits throughout both lungs, with quite a large 
area of cheesy pneumonia in the right middle lobe, and scattered miliary tubercles in 
other organs. 



TUBERCULOSIS. 102!) 

softened and broken down, and if the bronchus is a small one, the onlj 
result of this may be a rapid spreading of tuberculous infection through- 
out the lung. If sudden rupture occurs, a large caseous mass may escape 
into the trachea, or a large bronchus, with a result similar to thai pro- 
duced by any other foreign body. If suppuration occurs, the abscess 
may rupture into the surrounding cellular tissue, causing mediastinal or 
retro-cesophageal abscess. This may open externally at the suprasternal 
notch, or in the first or second intercostal space, or may ulcerate into anj 
of the large vessels, the oesophagus, or the pericardium. 

Pleura. — This is rarely normal in any case of tuberculosis. In acute 
general tuberculosis the only lesion may be a deposit of miliary tubercles 
upon the visceral pleura. In most of the other cases there are found 
fibrous adhesions over the part of the lung involved, binding it to the 
pericardium, the diaphragm, or the chest wall. The amount of thicken- 
ing of the pleura varies a good deal, but is rarely great. Pleurisy with 
a serous effusion is not common in infants or young children ; when ii 
occurs it is apt to be sacculated. Hemorrhagic exudation is very rare 
at this age. Empyema is also rare, being seen in but five per cent of 
my cases, and then it was small and sacculated. Pneumothorax and 
pyopneumothorax are very rare in children under three years of age. 

Heart. — It is exceptional for the pericardium to be affected even in 
the most generalised forms of acute miliary tuberculosis. In such cases 
the usual lesion is a deposit of a few gray tubercles upon the visceral 
surface. ■ In chronic cases other lesions analogous to those of the pleura 
may be seen, but all are rare in childhood. In rare instances miliary 
tubercles are seen upon the endocardium. 

Brain. — Tuberculosis of the brain is very common during infancy, 
being then associated in nearly all cases with general tuberculosis. Mili- 
ary tubercles are occasionally found in small numbers in cases which have 
presented no symptoms. The lesions of tuberculous meningitis have al- 
ready been described. Cheesy nodules are rare in infancy, being noted 
in but 2.5 per cent of my own autopsies, which were mainly on children 
under three years old; while in the Pendlebury Hospital cases, including 
those between four and twelve years old, they were noted in 24.4 per cent. 
These nodules vary in size from a pea to a hen's egg; they are usually 
associated with tuberculous meningitis, but they may exist alone. When 
they are large they rank as cerebral tumours, being most frequently seen 
in the cerebellum. 

Liver. — This is frequently involved in general tuberculosis, although 
it is doubtful if it is ever the seat of primary infection except in the con- 
genital cases. Usually the only lesion is the presence of miliary tubercles 
on its surface and in its substance, and in most cases these are not nu- 
merous. They are found in about two-thirds of the cases. In a smaller 
number there are tuberculous nodules of various sizes, especially about 



1030 THE SPECIFIC INFECTIOUS DISEASES. 

the biliary ducts. In Dearly every protracted case the liver is markedly 
fatty. In very late cases of tuberculosis of the hones, it is frequently the 
seat o\' amyloid degeneration. 

Spleen. — This is more frequently affected than the liver, but the 
lesions arc similar. The size of the spleen is not much increased if only 
miliary tubercles are present; but with tuberculous nodules it may be 
greatly enlarged. Amyloid degeneration is found under the same condi- 
tions as in the liver. 

Stomach. — Tuberculosis of the stomach is one of the rare lesions; 
both its contents and its acid reaction seem to protect it against direct 
infection from the mouth. Tuberculous ulcers w r ere seen in five of my 
autopsies, which is a larger proportion than is usually noted. 

Intestines. — That these are less seriously affected in infancy than in 
older children is rather surprising when we consider how susceptible are 
the intestines of infants to other forms of infection. The explanation 
of this difference seems to be that intestinal infection is usually sec- 
ondary to disease of the lungs, primary lesions being relatively rare. In- 
fants die from the more rapid tuberculous processes in the lungs or brain 
before there has been time or opportunity for secondary intestinal lesions 
of importance to occur. The intestinal lesions and those of the mesen- 
teric lymph nodes with which they are almost invariably associated, are 
described elsewhere. 

Peritonaeum. — In early infancy the peritonaeum is not often involved 
even in general tuberculosis, and at this age it is very rare for it to be the 
seat of the principal tuberculous process. In older children it is more 
frequent. In most cases of general tuberculosis there are only deposits 
of miliary tubercles; less frequently there are tuberculous nodules with 
other inflammatory products. The lesions in these cases are described 
w r ith Diseases of the Peritonaeum. 

Thymus Gland. — In five of my cases tuberculous nodules were found 
in the thymus gland, the size varying from a small pea to a hazelnut. All 
these were cases showing widely disseminated tuberculous lesions. 

Pancreas. — In four of my cases this organ also was the seat of small 
tuberculous nodules, all of them being cases of general tuberculosis. 

Uro-genital Organs. — Serious tuberculosis of any part of the urinary 
tract is very rare in children. Miliary tubercles were found in the kid- 
neys in about one-third of my autopsies on tuberculous patients. They 
are generally few in number. Large tuberculous nodules of the kidney 
I have seen but once in a young child. They are very rare before the 
fourteenth year. In four of my autopsies tuberculous nodules were 
found in the suprarenal capsules. Tuberculosis of the testicle has been 
observed in rare instances among children. 

Tuberculosis of the bones and of the external lymph nodes has al- 
ready been described. 



TUBERCULOSIS. \()^\ 



THE CLINICAL FORMS OF TUBERCULOSIS 

I. General Tuberculosis. — Cases of tuberculosis present a vide variety 

in their symptomatology, depending upon the seat of infection, the 
rapidity with which the bacilli are disseminated through the body, or 
the numbers in which they enter. The general symptoms often precede 
the local ones, but are not recognised as those of tuberculosis. Often it 
is not suspected until the process is quite well advanced in some one 
organ. 

In Infants. — The early symptoms in infancy are often only those of 
failing nutrition. The patients are pale, thin, do not gain in weight 
no matter how fed, and finally lose steadily without sufficient reason. 
There may be no cough or fever sufficient to attract attention, and the 
case may even go on to a fatal termination without anything else than 
simple marasmus having been suspected, tuberculosis being first recog- 
nised at the autopsy. 

More frequently, however, there are developed toward the end of the 
illness both the symptoms and signs of pulmonary disease and fever. 
These are generally found together, as the process in the lungs is usually 
the cause of the rise of temperature. The febrile symptoms are often 
not seen until the last two or three weeks of life. The course of the 
temperature is irregular. It is never of the hectic type and rarely high. 
The usual range is between 100° and 102° F. The pulmonary symp- 
toms are generally few and not very well marked. There is some cough, 
but it is rarely severe. The breathing is more rapid than would be ex- 
plained by the temperature alone. Severe dyspnoea and cyanosis are 
rare, and are seen only at the close of the disease. The physical signs 
are those of either localised or general bronchitis. Digestive symptoms 
are usually present late in the disease, but they are rarely due to a 
tuberculous lesion of the stomach or intestines. 

The progress of the case after constitutional symptoms develop is 
usually steadily downward, and the child lives but a few weeks at most. 
Death generally occurs from progressive asthenia without the develop- 
ment of any new symptoms, or cerebral symptoms rapidly develop, and 
the child is carried off in a few days by tuberculous meningitis. Some- 
times there is a rapid spreading of the disease in the lungs, and death 
occurs with symptoms of acute pneumonia. 

General tuberculosis in infants is to be differentiated principally 
from marasmus with bronchitis; less frequently it may be confounded 
with hereditary syphilis. 

In Older Children. — The development of active general tubercu- 
losis in older children is usually preceded by a protracted period of 
indefinite symptoms. They are persistently anaemic without evident 
reason; they lose weight; digestion is disturbed; the appetite is capri- 



1032 THE SPECIFIC INFECTIOUS DISEASES. 

cious; they sleep badly: they are irritable, fretful, and easily fatigued. 
These symptoms indicate only a gradual decline in general health, and 
may readily be explained by many other causes than tuberculosis. They 
should, however, excite a suspicion of tuberculosis in a child who by 
surroundings or inheritance is predisposed to that disease. 

After these indefinite symptoms have lasted for a few weeks fever is 
added. Sometimes the prodromal symptoms are absent or unnoticed, 
and fever is the first evident symptom. From the beginning of fever 
some cases progress rapidly to a fatal termination in two or three weeks. 
In the majority, however, the disease runs a slower course. The fever 
often exists without evident cause and without any local manifestations 
of disease. The temperature is not often high, but it is continuous. The 
tympanites and the rose-coloured spots are not present, but the general 
aspect of the patient is strikingly suggestive of typhoid fever. But the 
course of the temperature and the duration of the illness show that we 
have to deal with some other condition. 

After the fever has lasted from one to three weeks there develop some 
signs of localised tuberculosis, generally in the lungs, or the fever may 
decline gradually, and although the patient improves he does not get 
well. He is still weak and does not gain in weight, and the thermometer 
shows the existence of a very slight amount of fever. Before long he 
may grow rapidly worse and the course of the temperature becomes ir- 
regular, with alternate exacerbations and remissions. Such an irregular 
and inexplicable fever sometimes puzzles the physician for three or four 
weeks before the characteristic features which stamp the process as tuber- 
culous are present. Before very long wasting is added to the fever. This 
may not be rapid, but is progressive. The tuberculous cachexia is fre- 
quently unmistakable; but in most of the cases one must wait for the 
process to advance far enough in some one of the organs to give local 
signs or symptoms before he can be sure of tuberculosis. In four 
cases out of five this is in the lungs, and frequently repeated examinations 
of the sputum may reveal the bacilli. Less often it is in the peri- 
tonaeum, the brain, or a general infection of the lymph glands throughout 
the body. If in the lungs, the process manifests itself as a broncho-pneu- 
monia whose tuberculous character may sometimes be suspected from 
its location — the apex or the middle of the lung in front — but chiefly 
from the fact that the general symptoms, fever and wasting, have so long 
preceded the local signs. From this time, the course may be that of a 
typical tuberculous broncho-pneumonia. 

If the tuberculous process is localised in the brain, there may be vom- 
iting, headache, drowsiness, irregular pulse, irregular respiration, and 
finally convulsions and coma — in short, the symptoms of tuberculous 
meningitis; if in the peritonaeum, there are abdominal distention from 
gas or fluid, tenderness, pain, diarrhoea, or constipation; if in the lymph 



TUBERCULOSIS. ]{);•;> 

glands, there is a general enlargement of those Bituated externally, some- 
times with symptoms indicating similar changes in those at the root of 

the lung. 

II. Pulmonary Tuberculosis.— Tuberculosis of the lungs in children 
may be seen in a variety of clinical forms which correspond with the 
different pathological conditions. The pathologic;! 1 conditions are often 
associated, yet the main clinical types are sufficiently distinct to give 
quite a definite picture. These types are: (1) miliary tuberculoe 
the lungs; (2) bronchitis with small, scattered, tuberculous nodules: (3) 
tuberculous broncho-pneumonia with areas oi consolidation, often ex- 
tensive, which may be followed by caseation and excavation, or by chronic 
fibrous induration. 

Miliary Tuberculosis of the Lungs.— This is not a common form 
of pulmonary tuberculosis, but may be met with even in young infants. 




Fig. 205. — Miliary Tuberculosis of the Lungs. Infant fourteen months old; symp- 
toms of marasmus; no elevation of temperature; tuberculides of the skin; positive 
von Pirquet reaction; no pulmonary signs or symptoms. The radiograph shows 
great numbers of small tuberculous deposits scattered through both Lungs. 

Both the general and pulmonary symptoms and the physical signs are 
rather obscure and indefinite, and often the diagnosis is not made. Oc- 
casionally the only symptoms are those of marasmus, neither fever nor 
physical signs in the chest being present (Fig. 205). As I have seen 
it in young children, it has seldom been attended by high temperature, 



1034 THE SPECIFIC ENFECnOUS DISEASES. 

101° to 103° F. being the usual range. Throughout the greater part of 
the disease it is often Lower than this, and toward the close perhaps rather 
higher. It is not a hectic type of fever, and it seldom touches the normal 
line. 

The duration of the disease in these eases, after fairly definite symp- 
toms begin, varies from ten days to a month. At first, and often for 
two or three weeks, the temperature is almost the only symptom. Cough 
is slight, inconstant, and seldom loose. There is no sputum. The respi- 
rations are only moderately accelerated, in many cases not enough to 
draw attention to the lungs as the seat of disease. There is no rapid 
wasting, the loss in weight being usually not more than would be ex- 
pected with any other febrile disease. None of the other symptoms sug- 
gest tuberculosis. The usual problem in diagnosis is to discover the 
cause of the fever. Often the most careful examinations of the chest 
made daily reveal nothing more than a few scattered rales. These change 
in position from time to time, and it frequently happens that for days 
none are heard. After the disease has progressed somewhat further, the 
liver and spleen are generally enlarged. Cerebral symptoms may de- 
velop, and the case terminate as tuberculous meningitis, but more often 
it is the pulmonary symptoms which are dominant. The respirations 
become more rapid ; the cough is frequent, but rarely loose ; there may 
be attacks of cyanosis. Still the only definite signs are the rales, now 
fine and moist, and diffused generally over the chest. The case usually 
ends in death by exhaustion, but without rapid or marked wasting. One 
of the most striking things in the clinical picture is the disproportion 
between the severity of the general and pulmonary symptoms and the 
few physical signs in the chest. 

Tuberculous Bbonchitis. — This is not an infrequent condition 
even in infancy. In many, perhaps in most, cases it marks the earliest 
clinical stage of a tuberculous broncho-pneumonia, but this is not always 
true. The condition seems, therefore, of sufficient importance to require 
separate consideration. Besides bronchitis, there are found at autopsy a 
few small tuberculous nodules, and tuberculosis of the bronchial glands, 
although these may give neither signs nor symptoms during life. The 
symptoms of this condition are few and not distinctive, and may differ 
in no respect from bronchitis due to other causes. Tuberculosis may not 
even be suspected until the lesion has so far developed as to be classed 
as tuberculous broncho-pneumonia. Cough is present, but has nothing 
characteristic about it except its persistence. Fever may be absent for 
a long time, but comes as the disease advances. Then it is low and 
very irregular, the temperature generally varying from 99° to 101.5° F. 
There may be slow but progressive loss in weight, or the infant may 
gain regularly for a number of weeks in spite of the cough. This fact 
often leads to a mistake in diagnosis. The nutrition is influenced much 



TUBERCULOSIS. [036 

more by the condition of the digestive organs than by the tuberculous 
process. Other symptoms generally regarded as belonging to early tu- 
berculosis, such as pallor, anaemia, perspiration, etc., arc usually absent. 
The physical signs are few and not characteristic. Scattered rales, some- 
times coarse and sometimes finer, but inconstant, are all the signs that 
are present for a long time, often several weeks. 

Cases like these are recognised as tuberculous only by finding 
bacilli in the sputum or by one of the tuberculin tests. It has been my 
custom to consider as probably tuberculous every infant who has been 
for any length of time in contact with a tuberculous parent or other 
member of a household. Regarding all such infants as suspicious has 
led me in hospital practice to search the sputum carefully for bacilli, 
with the result of finding them, sometimes in great numbers, in infants 
whose only outward symptom was a moderate cough, and who were 
admitted to the hospital for some other reason. At other times the condi- 
tion has been unexpectedly discovered by making routine eye or skin lots 
in hospital inmates with tuberculin. A typical reaction having been ob- 
tained in a child not hitherto suspected, the diagnosis of tuberculosis 
has been subsequently confirmed by finding bacilli in the sputum, 
although the only signs in the chest were a few indefinite rales and the 
only outward symptom a moderate cough. How many infants there are 
with such a form of tuberculosis and how long such a condition may con- 
tinue without more definite signs developing, one can only conjecture; 
.but the number of such cases is, I am convinced, not small. They form a 
very distinct but important group of tuberculous cases. The regularity 
with which bacilli are present in the sputum indicates what a factor 
they may be in spreading the disease. How many recover and in how 
many the disease goes on to the development of more serious lesions it is 
impossible to say. 

Tuberculous Broncho-pneumonia. — This is altogether the most 
frequent form of tuberculosis seen in young children. It may he primary 
in the lungs or it may be secondary to tuberculosis elsewhere, most fre- 
quently in the bronchial glands. It may be preceded by constitutional 
symptoms such as those described under the head of general tuberculosis 
It may follow single or repeated attacks of what was apparently a simple 
acute bronchitis or broncho-pneumonia, whether it occurred as a primary 
disease or was in turn a sequel to one of the infectious diseases, especially 
measles, whooping-cough, or influenza. 

Tuberculous broncho-pneumonia, as a rule, begins more gradually, 
and its course is less rapid than simple broncho-pneumonia, its progress 
being generally marked by weeks. When primary it is often preceded 
by symptoms described as tuberculous bronchitis. When it follows one 
of the infectious diseases it is usually engrafted upon the original dis- 
ease without any intervening symptoms. The early symptoms arc cough, 



1036 THE SPECIFIC INFECTIOUS DISEASES. 

rapid respiration, fever, progressive weakness, and anaemia. The weight 

may be at first stationary, hut soon there is steady loss, which may con- 
tinue until there is marked emaciation. At first the usual range of tem- 
perature is from 100° to 102° P.; later it is rather higher than this. 
In many of the rases it differs Little from the temperature of simple 
broncho-pneumonia. Sometimes the general symptoms are severe and 
the physical signs wide-spread, and yet the range of temperature is not 
high. To be sure, this is occasionally seen in simple broncho-pneumonia, 
but it is more frequent in tuberculosis. The cough early in the disease 
is slight, but later becomes severe and often distressing. Tn infants and 
young children it may be of a paroxysmal character, resembling pertussis. 
Expectoration is not often seen in those under five years old. Bloody 
expectoration is very rare in children. 

The conditions in the lungs which give physical signs are bronchitis 
of the smaller tubes with areas of complete or partial consolidation. In 
character, these signs are identical with those of simple broncho-pneu- 
monia. They may be scattered throughout the whole of both lungs; 
but when localised they are more frequently in the upper than in the 
lower lobes, and more frequently in front than behind. Although both 
lungs are involved, they are usually not affected to the same degree. The 
patient may die before signs of complete consolidation are present; more 
often there are during the last few days areas of consolidation, as shown 
by bronchial breathing and voice and dulness. In some cases although 
w^ide-spread lesions are found at autopsy the physical signs during life 
are few and indefinite; sometimes there may be almost none. (See Fig. 
205.) 

From the beginning of acute symptoms the progress of the disease is 
steadily downward, death occurring as in simple broncho-pneumonia. 
The end is marked by cyanosis, great dyspnoea, weak pulse, and extreme 
prostration. In a few cases there develop shortly before death cerebral 
symptoms, indicating tuberculous disease of the brain. Such symptoms 
may be the first to lead the physician to suspect the process to be a 
tuberculous one. But even this is not conclusive, for one may be deal- 
ing with an acute meningitis due to the pneumococcus. Lumbar punc- 
ture will decide. 

In the more protracted cases there are found in the lungs caseous 
nodules, with larger areas of caseous pneumonia, and usually some areas 
of softening. The process is not usually so generalised as in the cases 
just described, but as in them there is always associated a certain amount 
of simple pneumonia. The pathological process may terminate (1) in 
diffuse caseation, or (2) in localised caseation and excavation, or (3) 
in partial resolution and the development of a chronic fibroid pneu- 
monia. In the first two varieties the progress is as a rule steadily down- 
ward to a fatal termination, which takes place in from one to three 



TUBERCULOSIS. 



io:i7 



mouths. In the third form, which is described later, there is partial 
recovery. 

The mode of onset will depend upon the conditions under which the 
disease develops. When the genera] symptoms of tuberculosis have pre- 
ceded those in the lungs, the evolution of the latter is gradual, with 
cough, rapid breathing, dyspnoea, increased prostration, etc. When the 
pulmonary symptoms are present from the beginning, they are the Bame 
as in simple broncho-pneumonia, with the exception that they usually 
come on less acutely. The latter is true of cases which are secondary to 
some other form of tuberculosis in the bones, peritonaeum, etc. 



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Fig. 206. — Tuberculosis Following Measles. Child sixteen months old, inmate of 
an institution. Chart begins on fifth day of a severe, but uncomplicated attack 
of measles, and shows a natural decline to normal. Fever then returned and con- 
tinued till death, twelve weeks later. Record for the period which is omitted was 
much like that which immediately precedes and follows. Early symptoms not acute. 
only slow wasting, slight cough and fever, with scattered rales throughout chest. 
Signs of consolidation not distinct till eighth week, then present in right upper lobe. 
Toward the end, rapid emaciation, marked pulmonary symptoms, and si<ms of cavity 
at right apex. Autopsy showed a large cavity, extensive tuberculous deposits 
throughout both lungs and in nearly all abdominal organs. 



When pulmonary tuberculosis follows measles (Fig. 206) or whoop- 
ing-cough which has been complicated by simple pneumonia, the early 
symptoms may present no unusual features. Alter two or three weeks 
the temperature gradually falls, and the physical signs improve, but 
neither quite disappears. The cough continues, though its severity some- 
what abates. In the course of a few weeks the child, who has meanwhile 



1 038 



THE SPECIFIC tNFECTIOUS DISEASES. 



improved somewhat in his general condition, becomes distinctly worse, 
often without any assignable cause. The temperature rises to 102° or 
103° F. : the cough increases, and an extension of the disease in the 
lungs is evident by the physical signs. In other cases the progress of 
the disease, after a pneumonia which complicates measles, is with- 
out an Intervening period of apparent improvement. It sometimes hap- 
pens that, the attack of measles or whooping-cough is not accompanied 
by any serious pulmonary symptoms, and the case goes on to apparent 
recovery, except that there remain anaemia, a slight cough, and fever. 
The temperature, although not high, persists ; but it may be two or three 
weeks before there are present definite symptoms and signs of disease in 
the lungs. 

Fever is a constant accompaniment of all active tuberculous processes 
in the lungs in the child as in the adult, it being absent only during the 
periods of remission which occur in the cases of slow and irregular prog- 
ress. It is a very important guide to the progress of the disease. The 
early fever may depend in part upon coexisting broncho-pneumonia, 
and its course may resemble that of simple pneumonia of the protracted 
variety. There is no typical curve. The fever is not often steadily high, 
and in many cases it is never high (Fig. 207). It frequently runs for 



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Fig. 207. — Tuberculous Pneumonia ; General Tuberculosis. Patient eleven months 
old, and under observation at the time he was taken sick. Chart of entire illness 
is given. Disease began as an acute pneumonia in lower part of left axilla and spread 
to entire lower lobe. Early signs of consolidation; at end of two weeks, flatness so 
marked that a needle was inserted, fluid being suspected. Vomited frequently, and 
had loose discharges from bowels throughout the illness; abdomen much swollen for 
last two weeks. Autopsy showed cheesy pneumonia of part of the upper and the entire 
left lower lobe, where there were two small cavities. Recent tubercles found through- 
out right lung, and extensive deposits in abdominal organs with peritonitis, and intes- 
tinal ulcers. 



several days between 99° and 102° F., and then, without evident cause, 
rises to 104° F. or over. In infants the morning temperature is fre- 
quently subnormal, although the evening temperature may be 102° or 
103° F. Even toward the close of the disease, when softening and break- 
ing down are actively going on, the regular hectic temperature of adults 
is rarely seen in a young child (Fig. 208). While the presence of fever 
is of great significance, its course has almost no diagnostic importance 
in early life. Especially should one beware of drawing the conclusion 



TUBERCULOSIS. 



io:w 



that, because the fever is not hectic, there is do breaking down of the 
lung. 

Sweating belongs only to the late stage of the disease, and is usually 
associated with the hectic type of fever; both these are regular Bymptoms 
in children over seven years old, but not in very young children. 



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Fig. 208. — Tuberculous Pneumonia with Extensive Softening and Excavation. 
A delicate child, thirteen months old; weight, 10 pounds; came under observation 
four weeks before death, with consolidation at apex of right lung. Signs increased 
in intensity, and extended in area until there were heard, from clavicle to below the 
nipple, exaggerated bronchial voice and breathing and many moist rales; percussion 
note was flat; behind, the same signs at extreme apex. No distinct signs of a cavity; 
no hectic fever; no sweating. Autopsy showed large cavity (Fig. 202) at right apex 
partly filled with caseous masses; diffuse caseous pneumonia (Fig. 203) of the rest 
of right upper lobe, with scattered deposits in the other lobes, the opposite lung, and 
a few in the abdominal organs. 



Wasting, like fever, is characteristic of active tuberculous processes. 
Whenever they are associated, tuberculosis should always be suspected, 
no matter how obscure the other symptoms may be. The wasting is 
not always rapid, but it is usually continuous while fever lasts. Dur- 
ing the periods of temporary improvement, children may not only cease 
to lose, but may actually gain in weight. In the early stage of the dis- 
ease, wasting is especially suggestive when it continues without apparent 
cause after measles or pertussis, or when it persists under other circum- 
stances in spite of a good appetite and apparently good digestion. It may 
at first be so slight as not to be noticed unless the scales are employed. 
In obscure cases this steady loss of weight is a point of much diagnostic 
value, and is frequently overlooked. Toward the close of the disease 
there is rapid and frequently extreme emaciation. 

Cough, although almost invariably present, shows no peculiarities. 
It may be hard, dry, or suppressed; it sometimes occurs in paroxysms 
resembling pertussis, which may or may not depend upon the presence 
of enlarged bronchial glands. 

Expectoration is absent in infants, the material coughed up being 
swallowed. In children over seven years old, we often gel a profuse 
muco-purulent expectoration, but it is very exceptional below this age. 

Haemoptysis is a rare symptom, but not unknown even in young 
children. Henoch has reported a ease of fatal haemoptysis in a child ten 



1040 THE SPECIFIC INFECTIOUS DISEASES. 

months old, where the haemorrhage was due to the rupture of an aneu- 
rism in the wall of a cavity. Herz, in 2^1 clinical cases of tuberculosis 
in children, records 8 of haemoptysis — 1 of them tinder five years, and the 
youngest only eighteen months old. The records of 131 autopsies on 
tuberculous children in the Pendlebury Hospital show that haemoptysis 
was tour times a cause of death; two of these patients were under five 
years, and one was only twelve months old. I have never met with a 
case of haemoptysis under five years old. 

The respiration is accelerated, and usually out of proportion to the 
rise in temperature. As the lung becomes more and more extensively 
invaded there is constant dyspnoea. The pulse is rapid in the early stage, 
and continues so throughout the disease ; tow r ard the end it becomes weak 
and irregular. Irregular respiration and a slow, irregular pulse may 
occur at any time from the development of cerebral complications. 

Pleuritic pains in the chest are not frequent in children. Gastro- 
intestinal symptoms, such as indigestion, vomiting, diarrhoea, etc., are 
generally present, but are not peculiar to this disease. They usually 
depend upon the patient's general condition, only exceptionally upon 
tuberculous disease of the stomach or intestines. The characteristic 
symptoms of intestinal tuberculosis — abdominal pain, tenderness, uncon- 
trollable diarrhoea, and intestinal haemorrhage — are seldom met w r ith 
in children under five years. I have seen but two cases. With such 
symptoms, and sometimes when they are doubtful or absent, careful 
palpation of the abdomen may disclose the presence of enlarged mesen- 
teric glands. When these are not readily felt through the abdominal 
walls, they may sometimes be discovered by a rectal examination. 

The spleen is often enlarged, sometimes very much so, but this does 
not occur with sufficient frequency to be of much diagnostic value. It 
may be due to tuberculous deposits, to causes connected with the lungs 
or heart, or to fever. The liver is not enlarged from tuberculous deposits, 
but may be so from amyloid or fatty degeneration, or from obstructed 
circulation, as in the case of the spleen. 

Dropsy is rare. It may depend upon anaemia, upon complicating 
nephritis, especially amyloid degeneration, upon cardiac or pulmonary 
conditions leading to interference with the return circulation, or upon 
pressure of tuberculous retro-peritoneal or mesenteric glands upon the 
inferior vena cava. Clubbing of the fingers is occasionally seen in 
cases running a very protracted course, and is due to obstructed cir- 
culation. 

Anaemia is commonly associated with wasting, and it is of special 
importance when the latter is slight or absent. It is a frequent sequel 
of acute disease in infancy when not dependent on tuberculosis; when, 
however, it is associated with low fever, cough, and persistence of rales 
in the chest, it should excite apprehension. 



TUBERCULOSIS. 1011 

Chronic Tuberculous Pneumonia. — In young children this is ■ 

chronic interstitial pneumonia associated with tuberculous deposits. 
These cases have usually had their beginning in one of the acute forms. 
There is a slow convalescence and apparent recovery, although this is not 
complete. Often a slight cough remains, or returns from tin- slightest 
exposure or other exciting cause. The child does not regain his former 
weight or vigour, and careful examination of the lungs shows thai Borne 
abnormal signs remain. 

After a few months, possibly, the child lias another attack resembling 
the first. It is accompanied by fever, cough, and perhaps there is a 
fresh consolidation of some part of the lung, generally in the neighbour* 
hood of the old disease. All active symptoms finally subside, and most 
of the signs of recent disease disappear; but it is then usually found that 
the condition of the lung is not quite so good as before this second 
illness. The acute attacks may be repeated several limes and pass 
under the name of bronchitis, broncho-pneumonia, or pleurisy. They 
may extend over a period of years. The general health in the interval 
is not good, there being present in most cases anaemia, with the usual 
symptoms of malnutrition; the children are regarded as very delicate. 

The course of this disease thus differs in no essential particulars from 
that of simple chronic broncho-pneumonia; the physical signs likewise 
are identical in character, although they may differ in their location. 
They are generally found in the same conditions as are the signs in the 
more rapid forms of pulmonary tuberculosis in early childhood. A fatal 
result in these cases is usually brought about by the development of 
acute tuberculous pneumonia or miliary tuberculosis of the lungs, by 
tuberculous meningitis, or by a simple broncho-pneumonia. 

Physical Signs of Pulmonary Tuberculosis. — Speaking gener- 
ally, except in situation there is little difference in a young child between 
the signs of a bronchitis or broncho-pneumonia due to the tubercle ba- 
cillus, and those of the same lesions when due to other causes. Cavities, 
although present at autopsy in most of the advanced cases, are seldom 
of such size or so situated as to be recognised during life. In children 
over six or seven years old, the signs are essentially like those in adults. 

The upper lobes are the seat of the most advanced disease twice as 
frequently as the lower lobes, and the right lung rather more frequently 
than the left. The region most often involved is the middle zone of the 
lung. If the signs appear first behind they are usually in the inter- 
scapular space; if in the lateral part of the chest, they are in the middle 
or upper part of the axilla; if in front, they are in the mammary region. 
The explanation is found in the fact that the disease in infants and 
young children so often extends from the lymph nodes at tin 4 root of the 
lung to the lung itself. The physical signs themselves may be grouped 
under four heads, corresponding to the pathological conditions existing 
67 



1042 THE SPECIFIC INFECTIOUS DISEASES. 

in the disease, viz., (1) bronchitis; (2) partial consolidation; (3) com- 
plete consolidation; ( \) excavation. The early signs are almost identi- 
cal with those described in broncho-pneumonia. As a rule, however, the 
transition o( the signs from one stage to another is much slower in tuber- 
culous than in simple broncho-pneumonia. 

Tuberculous bronchitis gives rales which may be of all sizes and 
varieties, localised or general. If the process goes on to a partial con- 
solidation there are gradually developed in addition slightly impaired 
resonance or even dulness, broncho-vesicular respiration, and increased 
voice. These signs are usually over a localised area. Later the signs of 
complete consolidation are present — marked dulness, increased fremitus, 
bronchial respiration, and. voice, but still rales and friction sounds are 
generally heard. 

The later signs depend upon what course the pathological process 
follows. If it terminates in a diffuse or localised caseation, the signs 
differ little from those of a lobar pneumonia with extensive and complete 
consolidation except that the dulness on percussion is usually greater. 
There may be even flatness, so marked as to suggest the presence of a 
pleural effusion. Empyema is often the diagnosis made. These signs 
may persist until the death of the patient from exhaustion. 

If the caseation is localised and followed by excavation, the signs 
of a cavity may be present. Cavities, however, are often so small and 
deeply seated as not to give definite physical signs. Furthermore, they 
are frequently filled with thick pus or cheesy matter, and rarely com- 
municate freely with the bronchi. If large and superficial they give the 
same signs as in adults. Like the areas of tuberculous pneumonia, they 
are most frequent in the middle zone of the lung in front. In the young 
child similar signs are often present where there are only dilated bron- 
chi associated with a fibroid condition, or when a superficial bronchus is 
surrounded by an area of diffuse caseation. Cavities are very often diag- 
nosticated when they do not exist, and quite as often overlooked when 
present. 

If the acute process terminates in a chronic tuberculous pneumonia 
the signs are those of an unresolved or slowly resolving pneumonia, in 
which the area of consolidation gradually diminishes, but the signs do 
not altogether disappear. When recovery goes further there may remain 
only some dulness on percussion, broncho-vesicular respiration, rales, 
and friction sounds. Such signs may last indefinitely, exacerbations and 
remissions occurring from time to time. These signs can not be dis- 
tinguished from those of simple chronic broncho-pneumonia. 

Diagnosis of Pulmonary Tuberculosis. — In arriving at a diag- 
nosis one should investigate the family history, surroundings, and pre- 
vious condition of the patient; also consider the mode of onset, the course 
of the disease, and the evidence afforded by the examination. 



TUBERCULOSIS. L043 

A careful examination of the family history and surroundings should 
be made to determine the existence of pulmonary tuberculosis in the 

parents or in other members of the household. Enquiry should also be 
made regarding meningitis, disease of the cervical glands, Bpine, hip, 
knee, or ankle, especially in other children of the family. Other condi- 
tions favourable for acquiring the disease should be considered, as in 
cases where a child has been reared in a tenement house, or lias been Lone 
an inmate of a hospital or other institution. In the child's previous his- 
tory, it is important to know if he has had measles or pertussis, and 
whether they were severe, accompanied by pulmonary complications, or 
followed by a protracted cough or obscure fever. The child's general 
constitution should be considered, whether he is delicate, narrow-chested, 
poorly nourished, or habitually anaemic. 

In its symptoms and course it is with simple broncho-pneumonia that 
tuberculous disease is likely to be confounded. The onset of simple 
pneumonia is usually rapid and often abrupt; tuberculous pneumonia 
usually develops gradually with constitutional symptoms preceding the 
local ones' by several days or even weeks. In acute tuberculosis one is 
often struck by the disproportion between the general symptoms — loss 
of flesh, prostration, and temperature — and the local evidences of pul- 
monary disease. When the pulmonary disease lasts longer than usual 
the question arises whether we have to deal with a case of persistent 
broncho-pneumonia or with tuberculosis. In children whose general 
condition is poor it is not infrequent for simple broncho-pneumonia to 
resolve slowly or to go on to the development of chronic interstitial pneu- 
monia, so that other means of diagnosis are needed. 

The course of the temperature can not be depended upon to differ- 
entiate any form of pulmonary tuberculosis from simple broncho-pneu- 
monia. Anaemia and wasting are usually more marked in tuberculosis, 
and in most cases they are progressive. A high leucocyte count, e. g., 
above 20,000 — especially when accompanied by a high polymorphonu- 
clear percentage, strongly favours pneumonia. Meningitis developing 
during a pulmonary disease of doubtful character is generally tubercu- 
lous, and its occurrence is usually to be interpreted as establishing the 
tuberculous nature of the process in the lungs. But acute pneumococcus 
meningitis may occur under very similar circumstances, and only a 
lumbar puncture may differentiate between them. A copious muco- 
purulent expectoration is seen quite as frequently in the other forms 
of chronic pneumonia as in the tuberculous variety. 

Examination for Bacilli. — Discovery of the bacilli in the sputum of 
even young infants is by no means impossible, nor even a very difficult 
matter. Both time and patience are required, and in most cases repeated 
examinations are necessary. Infants do not expectorate, but cough up 
the bronchial secretion into the pharynx and swallow it. Sputum must 



1044 THE SPECIFIC INFECTIOUS DISEASES. 

therefore be obtained from the pharynx or the oesophagus; to seek for the 
bacilli in the vomitus, as has been recommended, is almost a hopeless 
task. The method which has given me the most satisfactory results is 
to excite a cough by irritating the pharynx, and then to catch the sputum 
brought up into view upon a cotton swab or a bit of muslin in the jaws 
of an artery clamp. Inversion during a paroxysm of coughing some- 
times causes the infant to discharge a considerable mass of muco-pus 
into a sputum cup. By the procedure mentioned it has not been found 
more difficult to obtain good sputum for examination in very young 
patients than in adults. Good sputum may be described as muco- 
purulent masses, for bacilli are very seldom to be found in clear, glairy 
mucus. Following the method described, bacilli have been found in over 
eighty per cent of my hospital cases of pulmonary tuberculosis in infants, 
although in over half of them the disease was not advanced, judging 
by symptoms and physical signs. 

Bacilli may readily be found in the stools of many children suffering 
from tuberculosis. Their presence does not necessarily indicate a tuber- 
culous lesion of the intestines, for their source is more frequently a 
pulmonary lesion, the bacilli being coughed up and swallowed. Hence, 
it is sometimes easier to find them in the stools than in the sputum. 
They must be carefully differentiated from the smegma bacilli. 

III. Chronic Phthisis. — This form of tuberculosis, with its chronic 
hectic fever, slow cavity formation, progressive emaciation, night sweats, 
etc., is very rarely seen before the fifth year, and it is not at all frequent 
until the tenth or twelfth year. In its symptoms, course, termination, 
and physical signs, it resembles the same disease in adults, and need not 
be described at length here. 

IV. Tuberculosis of the Bronchial Lymph Nodes (Bronchial Glands). 
— This condition is usually associated with some form of pulmonary 
tuberculosis, but it may exist as the most important and sometimes as 
the only tuberculous lesion. 

Its symptoms are usually associated with those of pulmonary or gen- 
eral tuberculosis; but they may occur when the pulmonary changes are 
too few to be recognised either by symptoms or physical signs. From the 
great frequency with which this lesion is found in infants and young 
children, it might be expected that local symptoms would be common 
in such patients. They are, however, in my experience, quite exceptional. 
Most of the cases in which well-marked symptoms occur are in children 
over two years old, and it is between the third and tenth years that they 
are usually seen. In infancy, although these glands are almost inva- 
riably affected, death in the great majority of cases occurs from the 
pulmonary disease, before the later changes in the glands have had time 
to develop. 

General symptoms may or may not precede the local ones. The 



TUBERCULOSIS. KM.-, 

latter are chiefly mechanical, and depend upon the size of the glands and 
upon their anatomical relations, and very Little or not at all upon the 
nature of the changes in them. The most important relations, bo far ae 

the production of symptoms is concerned, are those which they bear to 
the pneumogastric and recurrent laryngeal nerves, the superior vena 

cava, the trachea, and bronchi; those less important arc to the aorta, 
pulmonary artery, and oesophagus. 

Pressure upon or irritation of the pneumogastric or recurrent nerves 
produces cough, dyspnoea, and sometimes a change in the voice. The 
cough is hoarse, persistent, and teasing, and frequently occurs in parox- 
ysms which in many respects resemble those of pertussis, hut it lacks 
the characteristic whoop, and is not accompanied by the expectoration of 
a mass of tenacious mucus. These paroxysms are severe and often pro- 
longed, but careful observation shows distinct differences from those of 
pertussis, though by an unfamiliar ear the two are easily confounded. 
The dyspnoea, like the cough, is paroxysmal, and sometimes Btrongly 
resembles ordinary spasmodic croup; at other times it is like a severe 
attack of asthma. Such symptoms may come and go, but they are fre- 
quently prolonged, and usually in the interval between the severe seizures 
the patient is not wholly free from dyspnoea. Although the chief cause 
of dyspnoea is no doubt nerve irritation, it may he due in part to pressure 
upon the trachea or one of the large bronchi. In dyspnoea from pressure 
on the trachea the head is usually thrown back, and the obstruction is 
more frequently on expiration than on inspiration. 

After such symptoms as those mentioned have existed for a few days 
or weeks, and in some cases without any warning, there may occur a sud- 
den attack of asphyxia which may prove fatal. This is generally due to 
ulceration of a caseous gland into the trachea or a large bronchus and 
the escape of a large mass into the air passages, where it produces the 
same effects as does any other foreign body. 

Of fifteen cases of this kind collected by Loeb, death by suffocation 
occurred in most in from five to ten minutes after the first definite symp- 
toms; in some the fatal attack was preceded for some time by milder 
attacks or by a cough; in others no previous symptoms wen 1 present, 
the child being apparently in perfect health. Rarely after ulceration into 
the trachea the patient has recovered after coughing up a large amount 
of foul pus. 

Pressure upon the superior vena cava is usually associated with spas- 
modic dyspnoea and cough, and causes cyanosis of the face and blnei 
of the lips. There is frequently a puffiness of the face, and there may 
be marked oedema. The coexistence of cyanosis with such oedema, when 
the urine is free from signs of renal disease, should always lead one to 
suspect pressure at the root of the lung. In some rare cases the interfer- 
ence with the return circulation has been so marked that meningeal 



1040 THE 'SPECIFIC INFECTIOUS DISEASES. 

haemorrhage lias resulted. By a process of ulceration set up by these 
glands they may open, not only into the air passages, but into the peri- 
cardium, the oesophagus, or any of the large vessels. The last mentioned 
is usually followed by instant death. Aldibert reports two cases in which 
the pulmonary artery was opened, death occurring from haemoptysis, as 
there was also a communication with one of the large bronchi. In 
VogePs ease the subclavian vein was perforated, and death resulted from 
the entrance of air. If ulceration takes place into the surrounding con- 
nective tissue, a mediastinal abscess may result, producing any of the 
pressure symptoms noted above, and, in addition, dysphagia from pres- 
sure on the oesophagus. Such an abscess may point in the suprasternal 
notch ; it may open through the chest anteriorly between the ribs or at 
the xiphoid cartilage; or it may burrow along the oesophagus to the 
peritoneal cavity. As a rule, however, patients die of general tubercu- 
losis before the local conditions have advanced so far. 

Physical Sigxs. — In order to produce physical signs, the mass of 
tuberculous lymph nodes must be large enough to form a mediastinal 
tumour, or so situated as to produce pressure on the trachea or bronchi. 
As a rule, the signs are more characteristic behind than in front. Per- 
cussion may give dulness anteriorly over the first piece of the sternum 
but very rarely posteriorly ; when present it is found along one or both 
sides of the spine from the third to the seventh dorsal vertebra. Auscul- 
tation posteriorly gives in the most marked cases a voice and respiration 
of a peculiar character, somewhat amphoric, but with a distinctly nasal 
quality. The auscultatory signs may so resemble those of a cavity that it 
is often difficult to believe that a cavity does not exist. If one of the pri- 
mary bronchi or one of its lobar divisions is compressed, there may be 
very feeble respiration over one lung or one lobe ; if the pressure is suffi- 
cient to prevent the entrance of air, or if one of these large tubes has 
been plugged by a caseous mass, there is an absence of respiratory mur- 
mur over a single lobe or an entire lung. This sign is of great diagnos- 
tic value, but it is not often present. 

Diagnosis. — Enlargement of the bronchial glands to a sufficient 
degree to produce symptoms, may occur in syphilis, in Hodgkin's dis- 
ease, and in various forms of malignant disease of the mediastinum. A 
certain amount of swelling is seen in nearly all cases of simple bronchitis 
or pneumonia, especially in those running a subacute or chronic course. 
Whether this simple hyperplasia is ever sufficient to cause such symptoms 
as those mentioned is exceedingly doubtful. I have myself never known 
it to produce anything more marked than a spasmodic cough. The great 
in frequency of other forms of enlargement sufficient to be of any clin- 
ical importance, usually warrants us, from the symptoms mentioned, 
in making the diagnosis of tuberculosis. The development in a child of 
a chronic abscess in the anterior mediastinum, is almost always due to 



TUBERCULOSIS. 



10-17 



tuberculous glands; and so is one in the posterior mediastinum, provided 
Pott's disease can be excluded. 

The most important points for diagnosis arc the association of a spas- 
modic cough with paroxysms of dyspnoea resembling asthma or croup, 
and oedema or congestion of the face. More Btrese is to be Laid upon 
the symptoms than upon the physical signs; the latter are at mosi only 
confirmatory. The chief difficulty in diagnosis is found in those cases 
which present few or no other signs of tuberculosis, and which come firol 
under observation with attacks of dyspnoea or asphyxia resemhling those 
seen in laryngeal stenosis. In many such cases tracheotomy has been 
done without finding any cause for the dyspnoea, the autopsy showing it 
to be due to the ulceration and impaction of a caseous gland. 




Fig. 209. — Tuberculous Bronchial Glands. 
A very large mass upon the right side, A, A; a smaller one upon the left side, B, B. 



In many cases very positive information is given by the X-ray. the 
radiographic shadows usually showing better on the righl side than on 
the left on account of the heart (see Fig. 209). This means of diagnosis 
is, however, of no value in distinguishing tuberculous glands from en- 
larged glands due to other causes; the latter, however, are very rare. 

The Tuberculin Tests. — The Fever Reaction Following Tuberculin 
Injections. — This is quite as reliable in children as in older patients. 1> 
is limited in its application, since most cases of active tuberculosis at 
this period of life are accompanied by fever. Since the other tests are 



104S THE SPECIFIC INFECTIOUS DISEASES. 

easier to employ and not open to the same objections, there is now very 
seldom a need for the use of this test. 

The Ophthalmic Test (Calmette or Wolff-Eisner Test). — This gen- 
erally gives reliable results, but its use is attended by some risk and it 
has no advantages over the von Pirquet test. 

The Cutaneous Test (von Pirquet* s Test). — Usually the forearm is 
the part chosen for inoculation. The skin is carefully washed with 
alcohol or ether. A small drop of pure tuberculin is placed upon the skin. 
With a small instrument resembling a tiny chisel a simple scarification 
for control is made at a distance of two or three inches from this drop. 
A similar scarification is then made through the drop. Linear scratches 
one-quarter inch in length with a sterile needle serve equally well as a 
means of inoculation and control. The child should be watched, and if 
very young the arm should be held until the skin is quite dry to prevent 
infection by rubbing. As an added precaution it may be covered with 
a piece of sterile gauze. The reaction consists in a red areola about the 
point or along the line of inoculation. This generally begins in from 
twelve to eighteen hours, rarely as late as twenty-four hours, and reaches 
its height during the next twenty-four hours. The diameter of the 
areola indicates the degree of reaction. It continues in most cases for 
from one to three days and slowly fades, often being followed by a slight 
local desquamation. Barely there may be vesiculation. There is in most 
of the cases slight infiltration of the skin readily appreciable to the touch ; 
and there may be a distinct induration. The more marked reactions con- 
tinue for from four to ten days. Any definite inflammatory reaction 
which follows this course may be regarded as positive. The arm should 
be observed daily to note the results. There seems to be no relation 
between the intensity of the reaction and the extent or the activity of 
the tuberculous disease. 

The Puncture Test (Sticlt-reaction of Hamburger). — There is in- 
jected just beneath the skin of the forearm a measured dose, from y^ 
to toW mgr. of tuberculin. The reaction is seen at two points; the 
greater, corresponding to the place where the fluid is deposited, the less, 
where the needle perforates the skin. Swelling, redness, induration and 
local rise of temperature are present. The reaction begins within the 
first twenty-four hours; the induration and discolouration of the skin last 
five to six days and slight desquamation follows. A reaction beginning 
later than twenty-four hours is not diagnostic. Hamburger's statement 
that in older children this is the most sensitive of all tests seems probable. 

Inunction Test of Moro. — There is used for this test tuberculin made 
up with anhydrous lanolin, fifty per cent strength. A mass of this, the 
size of a pea, is rubbed for half a minute into the skin of the abdomen 
or chest over an area two inches in diameter. The reaction consists in 
the formation of a papular, sometimes a vesicular, eruption which ap- 



TUBERCULOSIS. 1049 

pears, according to the severity of the reaction, in from twelve to forty- 
eight hours. It remains for several days and slowly disappears, being 

followed by pigmentation in the severer cases. 

A Comparison of the Different Tests. — No one of the i o ab- 

solutely conclusive as is the demonstration of the tubercle bacillus in the 
sputum, the cerebro-spinal fluid, or elsewhere. One should not therefore 
depend upon local tests and omit the search for bacilli, even though it 
involves greater labour. While these tests when followed by a positive re- 
action furnish evidence of the existence of a tuberculous lesion, they do 
not enable us to distinguish between latent and active conditions. Thus, 
a child may give a positive skin reaction when suffering from acute 
pulmonary disease, which by its course is shown to he non-tuberculous; 
although grave suspicion of an acute pulmonary tuberculosis may have 
existed and apparently be confirmed by the tuberculin test. Much need- 
less alarm may therefore be produced by a positive reaction, which really 
demonstrates only that somewhere the child has a tuberculous focus, 
but it does not prove that his present disease is of a tuberculous nature. 

Shortly before death, whether from general or any form of localised 
tuberculosis, as a rule there is no reaction to any of the local tests. 
Likewise, a child in an extremely asthenic condition from any cause 
whatever may give no reaction although he has a latent tuberculosis. 
During active measles also the test is of little value. Xo conclusions 
therefore can be drawn from tests made under these conditions. On the 
whole von Pirquet's cutaneous test is to be preferred for general use. 

Tuberculides of the Skin. — These are at times of considerable value 
in the diagnosis of tuberculosis in general. 1 Although seldom seen in 
the acute varieties, they are not uncommon in the more slowly progress- 
ing forms. The distribution of the lesions is fairly constant. They are 
found chiefly on the buttocks, lower abdomen, genitalia and thighs. The 
number present is generally small, half a dozen to a dozen ; but they a re 
sometimes numerous and may be widely distributed. The lesion begins 
as a minute red papule, which is soon surmounted by a small vesicle. 
This dries to form a crust. If the crust is removed a small pit-like 
depression remains, which heals quickly, leaving a white, glistening 
scar surrounded by a pigmented border. The lesion runs its entire course 
in two or three weeks. Tubercle bacilli are often present but difficult 
to demonstrate. Tuberculides of the skin in young children are evidence 
of a widely disseminated process and are a very had prognostic sign. 
Such patients rarely survive more than a few weeks. 

General Prognosis of Tuberculosis.— The outlook for a young child 
with general or pulmonary tuberculosis is always had. So long as the 
disease remains confined to the lymph nodes, the child is not usually in 



1 Tileston, Archives of Internal Medicine. July, L909. 



1050 THE SPECIFIC INFECTIOUS DISEASES. 

danger, except from accidents connected with their softening and ulcer- 
ation, which after all arc rare. Spontaneous cure may occur in these 
glands in the same way as in others in the body, viz., by encapsulation, 
calcification, etc. Such a result is no doubt a very frequent one; exactly 
how often it occurs it is impossible to say. But when once the disease 
has gained any headway in the lung itself, its steady advance is almost 
certain in a young child. In those who are older and have more resist- 
ance the chances of an arrest of the process are much greater. 

If the bacilli have gained entrance into the body in any considerable 
numbers, even though they are shut up in an encapsulated, caseous, 
bronchial gland, the patient is never free from the danger of general 
infection. 

Prophylaxis. — The prevention of tuberculosis must have constant ref- 
erence to its cause. The first essential is the destruction of the tubercle 
bacilli wherever they exist. Since most of those existing in the air 
are derived from the sputum of patients affected with pulmonary tuber- 
culosis, it should be insisted upon, everywhere and at all times, that the 
sputum from such cases should be collected in special cups or cloths and 
destroyed either by germicides or by fire. The next point is to avoid 
needless exposure. A tuberculous mother should on no account nurse 
her child nor kiss it upon the mouth. A wet-nurse likewise should be 
free from any tuberculous taint. No nurse or other care-taker should 
ever be employed about children who has, or ever has had, pulmonary 
tuberculosis. It is wise to exclude also those who suffered when chil- 
dren from tuberculosis of the bones or the cervical glands, although the 
danger from such persons is extremely slight. If active tuberculosis 
exists in any member of the family, a young child should be kept away 
from the room, and if possible should not reside in the house. On no 
account should infected persons be allowed to kiss children or sleep in 
the same bed with them. The danger from drinking-cups and other 
dishes should not be forgotten. A tuberculous person should either have 
his special dishes, or the utmost care should be taken to boil all those 
which he has used. Cows whose milk is used for children should be 
under regular veterinary inspection and should have passed the tuber- 
culin test, In any case when the slightest doubt regarding the health of 
the cows exists, or when the source of the milk is unknown, the milk 
should be heated to a temperature of 140° F. for forty minutes. The 
danger of infection through the alimentary canal is very much less than 
through the respiratory tract, and consequently the precautions first 
mentioned are much more important than those relating to the food, 
although the latter should on no account be neglected. 

In the case of delicate children and those with tuberculous parents or 
with other tuberculous near relatives, everything possible should be done 
to fortify them against the disease. They should be kept under more or 



TUBERCULOSIS. [05] 

less constant medical supervision. Attacks of bronchitis or broncho- 
pneumonia should be watched with the greatest solicitude. Exposure to 

influenza, measles or pertussis should especially be avoided. The coun- 
try rather than the city should be chosen for residence, and the child 

should spend the winter and spring in sonic warm, dry climate. Parents 
should be distinctly taught that watchfulness and care do not mean cod- 
dling or the keeping of children in the house the greater part of the 
time. Such children should live as much as possible in the open air, 
and every form of sport encouraged which tends to keep them there. 
Overheated houses are one of the most prolific agencies in perpetuating 
a delicate condition of health. Plenty of fresh air in sleeping apart- 
ments should always be insisted upon. All catarrhal troubles of the nose 
and pharynx should receive early and prompt attention, especially should 
hypertrophied tonsils and adenoid growths of the pharynx he removed, 
since these are conditions which form a most favourable nidus tor the 
growth of tubercle bacilli. 

Treatment of General and Pulmonary Tuberculosis. — If fresh air and 
a proper climate are necessary for the cure of this disease in adults, they 
are tenfold more necessary in the case of children. Without them there 
is little hope for a child with active pulmonary tuberculosis. Nowhere 
do these cases do so badly as in a hospital located in a city, and no class 
of hospital cases do worse than these. The same regions that are bene- 
ficial for adult cases usually agree with children, with the exception that 
the latter, as a rule, do better in a warm than in a cold climate. Plenty 
of fresh air and sunshine are essential. A child must be where he can 
be kept in the open air for the greater part of each day, in spite of 
fever, cough, or other acute symptoms. 

For the most acute cases when the children are confined to the bed, 
the largest, best- ventilated, and sunniest room available should be secured. 
and the windows should be constantly open. The general management 
of such cases is the same as for those with acute pneumonia. 

Xo specific remedy for tuberculosis has as yet stood the test of ex- 
perience. The diet is a matter of the utmost importance. Tuberculous 
patients must be fed like most other sick children, care being taken not 
to disturb the digestion by the unnecessary use of drugs. For a staple 
article of diet, milk is the best, and when this is not well borne some of 
its substitutes— buttermilk, kumyss, matzoon, etc.— may be tried. Cream 
is almost as useful as cod-liver oil, and should be given in one form or 
another whenever the child's digestion can tolerate it. 

Tuberculin in the treatment of this disease in young children has as 
yet been too little employed to enable one to form any definite conclu- 
sions as to its value. Its application should be directed by the same 
rules as those employed in adults. It is a therapeutic procedure which 
deserves more attention than it has hitherto received. 



1052 THE SPECIFIC INFECTIOUS DISEASES. 

The two drugs which are most useful are ereosote and cod-liver oil. 
Creosote may be given both by the stomach and by inhalation, as in cases 
of pneumonia. By the stomach there may be used for older children, the 
Bhellac-coated pills or capsules containing one or two drops of creosote; 
it may be given in conjunction with cod-liver oil. Cod-liver oil is usually 
best given in a fresh emulsion, although some children hear the pure oil 
better than its preparations. Inunctions of this or other oils are of some 
value when not well tolerated by the stomach. Arsenic, iron, and the 
compound syrup of the hypophosphites are all useful as general tonics, 
hut as specifics their action is very questionable. 



CHAPTER XI. 
SYPHILIS. 

Syphilis is a communicahle disease due to a specific organism, the 
spirochceta pallida of Schaudinn. In acquired syphilis this is found in 
the primary lesion, in the mucous patches and in the lymph nodes. In 
hereditary syphilis it is found in the cutaneous lesions, in the fissures 
at the angle of the mouth and in the mucous patches of the buccal 
cavity, with less regularity, in the internal organs, especially the liver 
and spleen. While in the still-horn child and in early cases, the num- 
ber of organisms found is very great, they are not so numerous at 
a later period, and they diminish rapidly after treatment is begun. 
In the late lesions the spirochete are not numerous, and are .difficult 
to demonstrate. 

In infancy and childhood both the acquired and the hereditary forms 
of syphilis are seen. 

ACQUIRED SYPHILIS. 

While acquired syphilis is very much less frequent than the hered- 
itary variety, it is by no means a rare disease in early life. It is not im- 
probable that some of the manifestations of syphilis in later childhood 
which are usually denominated " late hereditary syphilis," are really 
due to the acquired form. 

Etiology. — An infant may be infected by its mother during parturi- 
tion; but this is extremely rare and can take place only when there are 
lesions upon the mother's genitals. Infection is more likely to be from 
a mother who contracts syphilis subsequent to the birth of the child, 
and may occur through nursing or accidental contact by kissing, etc. 
In either of these ways children may be infected by wet-nurses, or from 
a venereal sore upon the nipple. Whether syphilis can be communicated 



HEREDITARY SYPHILIS. [053 

through the milk when the nipple is perfectly healthy and free from 

fissures, is somewhat doubtful. 

Syphilis may be communicated directly from a syphilitic child to one 
who is healthy by kissing, by sexual contact, or indirectly by means of 
bottles, spoons, cups, clothing, etc. The latter mode of in lection is mosl 
likely to occur in institutions. Vaccination was formerly a not infre- 
quent mode of communicating syphilis, but since the genera] introduc- 
tion of bovine virus this is very rarely seen. Cases have been recorded 
where the disease has been conveyed by the rite of circumcision, either 
from the mouth or the instruments of the operator. 

The relative frequency of the different sources of infection is shows 
by Founder's statistics of 40 cases: The source of infection was the 
parents in 19; nurses, in 8; servants, in 4; sexual contact, in 4; vaccina- 
tion, in 2; other children, in 2; a physician, in 1. The ages at which 
the disease was acquired in this series of cases were as follows: During 
the first year, 19 ; during the second year, 10 ; during the third and 
fourth years, 7 ; from the fifth to the fourteenth year, 6. 

Symptoms. — T he symptoms of acquired syphilis in children are in all 
respects similar to the same disease in the adult. A primary sore is pres- 
ent at the site of infection, which is most frequently the lips, the mouth, 
or some part of the face; very rarely is it seen on the genitals. There 
are very few individual symptoms belonging to hereditary syphilis which 
may not also be present when the disease is acquired. Its course, how- 
ever, is very much milder in the latter and a fatal termination is rare. 
Fournier states that of his forty-two cases only one died of marasmus. 
This marked contrast to hereditary syphilis is due chiefly to the fact that 
in the acquired variety the infant is rarely affected during the early 
months of life, a time when hereditary syphilis is so very fatal. 

Tertiary symptoms may appear at any time from three to twenty 
years after the original infection. 

The treatment is the same as that of hereditary syphilis. 

HEREDITARY SYPHILIS. 

Etiology. — If both parents are syphilitic, the child is usually but not 
invariably so. The symptoms, however, are not more severe than when 
the inheritance is from one parent only. The likelihood of transmission 
depends upon the stage of the disease in the parents. If the mother 
is suffering from secondary symptoms, transmission is almost certain. 
If active treatment has been employed for several months. If the child is 
born at a period when no active symptoms are present, or if the symptoms 
are of a tertiary character, the offspring will probably escape. First-born 
children are more likely to suffer severely from syphilis than the later 
ones, provided infection of the parents has taken place prior to the birth 
of all the children. 



1054 THE SPECIFIC INFECTIOUS DISEASES. 

The transmission of syphilis from the father without the intermedi- 
ate infect ion of the mot hoi- was once held to be possible. At the present 
time, however, this question must be placed among those not yet defi- 
nitely settled. There can be no doubt that in the vast majority of the 
cases the infection of the child is from the mother. 

If both parents are healthy at the time of conception and the mother 
becomes infected during her pregnancy the child may or may not be 
syphilitic. Transmission to the child is much less likely to occur if the 
mother is infected during the last two months of her pregnancy than 
earlier, although, as Hutchinson's cases conclusively show, there is no 
certainty that the child will escape. Diday states that if the mother is 
infected before the fourth week and proper treatment is instituted, the 
child will usually escape on account of the relation of the embryo to the 
maternal circulation during this early period. 

In 1837 Colles enunciated the following proposition, the truth of 
which has been abundantly verified since his time : " A new-born child 
affected with inherited syphilis, even although it may have symptoms in 
the mouth, never causes ulceration of the breasts which it sucks if it be 
the mother who suckles it, although continuing capable of infecting a 
strange nurse/' 

Caspary inoculated with syphilis a woman, apparently healthy, who 
had aborted with a syphilitic child; the result was negative. A similar 
experiment was made by Neumann, w r ith a like result. Widal reports a 
ease of an apparently healthy woman who had a syphilitic child by an 
infected husband ; later, by a second husband who was free from syphilis, 
she had a syphilitic child. The conclusion seems irresistible that the 
carrying of a syphilitic child gives immunity to the mother against the 
disease, and that this immunity is due to the fact that she herself suffers 
from syphilis, or a modification of that disease. The mother under 
these circumstances can not be inoculated, either by her syphilitic nurs- 
ing infant or artificially. 

That hereditary syphilis is contagious is conclusively shown by a 
number of recorded instances in which a healthy wet-nurse has been 
infected by a syphilitic infant. However, such examples of contagion 
are very rare, and many writers of large experience state that they have 
never seen it. It is certainly true that the danger of spreading infection 
from a case of hereditary syphilis has been exaggerated. 

Lesions. — Death may be due to syphilis, and yet the autopsy may re- 
veal no characteristic anatomical changes, and in fact there may be no 
demonstrable changes in any of the organs except the presence of the 
spirochaeta. 

Bones. — In the case of a syphilitic foetus, a still-born child, or one 
dying soon after birth, the changes in the bones are more uniformly 
present than are any other lesions. They are, in fact, rarely wanting, 



HEREDITARY SYPHILIS. [055 

and it is by them usually thai syphilis is recognised post mortem. The 
long bones are principally affected, the most important changes being 
found at the junction of the shaft with the epiphyseal cartilage. The 
lesion is termed an epiphyseal osteochondritis or acute epiphysitis. 
There is in the early stage congestion, swelling, and cell proliferation, 
which may be followed by separation of the epiphysis, suppuration in the 
neighbouring joint, osteomyelitis, and necrosis. These changes are more 
fully considered under Diseases of the Bones. 

Liver. — This is probably more frequently involved in the foetus and 
newdy-born infant than any other organ. The syphilitic Lesions of the 
liver consist in an interstitial hepatitis, a gummatous hepatitis, or a 
combination of the two varieties. 

In the interstitial form, which is most frequent in infancy, there is 
first a congestion and swelling of the organ, with the exudation of leuco- 
cytes in groups. The liver is enlarged, frequently very much so, hut 
presents few other gross changes. Later, new connective tissue forms, 
and atrophy of the liver cells takes place, with obliteration of some of 
the portal and hepatic vessels. This process may be diffuse, hut it is 
usually in patches. Groups of miliary syphilomata may also be found. 
If the process is diffuse, the liver is large, firm, and of a grayish-yellow 
colour. If it is localised, the affected areas are yellow or gray and the 
other parts are normal. 

The gummatous form is not frequent in early infancy, but belongs to 
a little later period. In this there may be miliary syphilomata with 
interstitial changes, and in addition the formation of small or large 
gummatous tumours, which may be softened at the centre. They are 
surrounded by zones of new connective tissue and the liver cells are 
atrophied. Amyloid changes may be present. 

In the late form of hereditary syphilis, usually seen in children over 
four or five years old, the liver is occasionally affected. The lesions 
resemble those of the congenital variety. There are found cirrhotic 
changes, which may be diffuse or circumscribed, and gummatous deposits, 
which vary from a minute size to that of a cherry; there may he amyloid 
degeneration. 

Spleen. — This is almost invariably enlarged in newly-born children 
with syphilis and in syphilitic foetuses, but nothing characteristic is 
found under the microscope. In older children the enlargement of the 
spleen is apt to be greater; the organ may be the seat of interstitial 
changes, and sometimes there may be gummatous deposits. These 
changes are rare in children under two years of age. 

Respiratory System.— In syphilitic infants who are still-born and 
in those who die soon after birth, there is frequently found in the lungs 
what is known as "white pneumonia." This process consists in fatty 
changes in the epithelium of the air vesicles; with this there is associated 



1056 THE SPECIFIC INFECTIOUS DISEASES. 

a certain amount of interstitial pneumonia, which ia chiefly peribron- 
chial. In older cases the interstitial pneumonia is extensive, and the 
lungs max be the seat of gummatous deposits, which soften and form 
small cavities. Accompanying these changes there may be bronchiec- 
tasis, emphysema, and the usual secondary lesions which follow chronic 
interstitial pneumonia. In syphilitic infants there is a strong tendency 
for all inflammations of the lungs to become chronic. 

The trachea and bronchi are in rare cases the seat of stenosis, which 
results from cicatrisation following the softening of gummatous de- 
posits in their walls. Lesions of the larynx are also infrequent. There 
is usually perichondritis, which more often involves the epiglottis than 
any other part, and sometimes there is the formation of papillomatous 
masses; but' ulceration and stenosis are both rare. 

The nasal mucous membrane in the early stage of the disease is very 
constantly the seat of a chronic catarrhal inflammation, which may be 
accompanied by superficial ulceration. In the late cases there is deeper 
ulceration, from the breaking down of gummata, with extension to the 
periosteum, cartilages, and bones, causing perforation of the septum, 
necrosis of the bones, etc. 

Xenons System. — Syphilitic lesions of the brain and cord are rare in 
children as compared with adults, and they are especially so in infancy. 
The most characteristic cerebral lesion of the newly-born child is hydro- 
cephalus, which may depend upon ependymitis, as in two cases reported 
by D'Astros, the disease proving fatal in the second month. Syphilitic 
meningitis is exceedingly rare under two years. There is occasionally 
seen in young infants a chronic basilar meningitis of syphilitic origin. 
Chronic pachymeningitis associated with gummata has been observed as 
early as the fourth year. There have been reported in infants a few 
cases of chronic meningitis with great thickening of the dura mater and 
cerebral sclerosis. 

Xearly all the syphilitic lesions of the nervous system which are seen 
in adult life have been observed in childhood, but infrequently, and in 
young children they are extremely rare. 

Heart and Arteries. — These may be affected even in young infants. 
Adler, of four cases examined, found two in which well-marked lesions 
were present in infants under four months. There was endarteritis of 
the coronary arteries accompanied by the early changes belonging to 
interstitial myocarditis. Chiari has reported syphilitic endarteritis of the 
brain at fifteen months, followed by thrombosis and softening. 

J Jig est ire System. — Chronic catarrhal pharyngitis is almost a con- 
stant symptom of the early cases. Later there is seen superficial or deep 
ulceration of the pharynx, tonsils, or fauces, which may lead to perfora- 
tion of the soft palate or to the formation of condylomata. 

There are no important lesions of the stomach or intestines either 



HEREDITARY SYPHILIS. [057 

with early or late syphilis. The rectum is occasionally the scat of ulcera- 
tion, and condylomata may form even in young children. 

Organs of Special Sense. — Otitis is a frequent accompaniment of the 

early syphilitic pharyngitis. It is very likely to become chronic, and in 
many cases results in a permanent impairment of hearing, [ritia is rela- 
tively rare in children, but it may occur even in Lntra-uterine life, as 
shown by the presence of adhesions in newly-horn children. It is usually 
seen in infants four or five months old, and is always serious. I ntersi it ial 
keratitis occurs frequently as a late manifestation of syphilis. Choroiditis 
and optic neuritis are both occasionally seen, hut they are rare. 

Genito-urinary Organs. — Nearly all these may be affected, but gener- 
ally in the late period of the disease. There may he chronic interstitial 
nephritis and more rarely gummatous deposits in the kidney, interstitial 
changes in the suprarenal bodies, and orchitis, which usually affects the 
body of the organ, rarely the epididymis; it is generally an interstitial 
inflammation, with or without gummatous deposits. 

Among the less frequent visceral lesions may be mentioned aba 
of the thymus, which are usually small and multiple; enlargement of the 
pancreas, with an increase of connective tissue and glandular atrophy; 
and chronic peritonitis. The lesions of the mucous membranes will be 
considered under Symptoms. 

Symptoms. — As the result of syphilis, abortion may take place at any 
period of pregnancy, with the discharge of a dead or macerated foetus, or 
the child may be still-born at term, or it may be born alive prematurely, 
but with so feeble a vitality that it survives but a few hours. Under 
these circumstances it is often difficult and sometimes impossible to de- 
cide positively with reference to the existence of syphilis. Maceration of 
the foetus or peeling of the skin is no proof, and even the examination 
of the internal organs may not be conclusive, except for the presence of 
spirochaetae. Lomer examined 43 foetuses, all dying before the thirtieth 
week of pregnancy; he found the spleen and liver enlarged in all, and 
marked bone changes in 21. Birch-Hirschfeld examined 108 newly-horn 
sy^philitic infants; he found the spleen invariably enlarged ; typical bone 
changes were present in 35, but in many cases the bones were normal. 
Mervis, from an examination of 92 syphilitic foetuses, states that no 
eruption upon the skin was found earlier than the eighth month. 

Symptoms are present at birth in only a small number of eases. In 
such there is usually a very severe degree of infection, and the infants 
do not often live more than a few days. Upon the skin there may he 
seen an eruption of pustules, papules, or bullae. The bullae are usually 
upon the soles and palms, but may be found upon other parts of the body. 
The name " syphilitic pemphigus " is often given to this condition. The 
bullae are at first small, and then coalesce ami form larger ones two inches 
or more in diameter. They contain a turbid serum which is sometimes 
68 



1058 THE SPECIFIC INFECTIOUS DISEASES. 

tinged with blood, and sometimes yellow from pus. Pustules, when pres- 
ent, are usually Been upon the face 4 or scalp. The general appearance of 
these infants is wretched in the extreme. The body is wasted, the skin 
wrinkled, and temperature subnormal. The spleen is usually enlarged 
and often the liver also. Death usually occurs from inanition within 
two weeks. 

In the great majority of cases the infant appears healthy at birth, 
and continues so for a variable time before the manifestation of the char- 
acteristic symptoms of syphilis. As a rule, the more intense the infec- 
tion, the earlier the symptoms make their appearance. The earliest 
symptoms are generally seen between the second and the sixth weeks. 
If three months pass without evidence of syphilis, the probabilities are 
that the child will escape. Miller (Moscow) gives the following statistics 
of the time of beginning of symptoms in 1,000 cases : 

Symptoms appeared during the first week 85 cases. 

" " " second week 138 " 

" third week 240 " 

" fourth week 177 " 

" fifth week 86 " 

" sixth week 54 " 

" seventh week 50 " 

" eighth week 30 " 

After the eighth week 140 " 

Sometimes the constitutional symptoms — wasting, cachexia, etc. — 
are noticed before the local ones, but usually this is not the case. Gener- 
ally the first symptom is the coryza or " snuffles/' which resembles an 
ordinary cold in the head, except that it persists. It is accompanied by 
a hoarse cry, indicating that the larynx participates in the catarrhal in- 
flammation. Soon the eruption makes its appearance, being generally 
first seen upon the hands, feet, and face. Fissures and mucous patches 
may be seen upon the lips, about the anus, and elsewhere. There is often 
slight fever, from 99° to 101° F. There may also be observed excessive 
tenderness and swelling about the shoulders, elbows, wrists, or ankles, 
due to acute epiphysitis, which may cause the child to cry from the 
slightest amount of handling, and the limbs may be moved so little that 
paralysis is suspected. 

In a severe case, as these local symptoms develop, the infant's gen- 
eral nutrition surfers. He loses steadily in weight, he becomes extremely 
anaemic, and whines and frets almost continually, but especially at night. 
The features have a pitiful, drawn expression; and the face is wrinkled, 
giving the infant a very old appearance. The skin has a peculiar sal- 
low colour, which has been well described as cafe au lait. The symp- 
toms may continue until a condition of extreme marasmus is reached, 
or death occurs from some intercurrent affection of the lungs or diges- 
tive organs. 



HEKKDITAin SYPHILIS. 



IO.V.) 



In the milder forms of infection the severe constitutional symptoms 
described are not seen, although the local evidences of disease are well 
marked. The severity of the symptoms is also much modified by treat- 
ment, especially when this is begun early. 

The most important local symptoms are the coryza, eruption, fissures 
about the mouth and anus, mucous patches, painful swellings ai the ex- 
tremities of the long bones, pseudo-paralysis, and onychia. 

Coryza. — In most of the cases this is the first symptom. Beginning 
like an ordinary catarrh, it is distinguished by ils severity and its per- 
sistence. There is a copious discharge of mucus and serum, often tinged 
with blood. Thick crusts form, which produce the usual symptoms of 
nasal obstruction; there is great difficulty in nursing; the infant breathes 
through the mouth, and the mucous membrane of the mouth is dry, caus- 
ing great discomfort. If untreated, the process, which at fust involves 
the mucous membrane only, may extend to the submucous tissue, causing 
ulceration; but the cartilages and the bones of the nasal fossa' arc not 
involved till a later period in the disease. 

The nasal catarrh is associated with more or less laryngitis, causing 
hoarseness or aphonia, and rarely there may be laryngeal stenosis. Dil- 
lon Brown has reported one case in an infant six weeks old, which recov- 
ered after intubation. 

Eruption. — The early eruption usually appears after the coryza has 
lasted about a week; but the two may come at the same time: or the 
coryza may be absent or so 
slight that the rash seems 
to be the first symptom. 

Occasionally there is 
seen a diffuse blush or ro- 
seola, but more frequently 
the eruption is macular, 
occuring in small, dark- 
red spots about the size of 
the infant's finger nails, 
usually circular and often 
slightly elevated ; there is 
no surrounding inflamma- 
tion, and rarely any itch- 
ing. It is usually most 
abundant upon the face, 
the neck, and the extensor 
surface of the upper and 
lower extremities, espe- 
cially the hands and feet, sometimes extending over the entire body. 
although it is generally scanty over the chest and abdomen. At first the 




Fig. 210. — Early Eruption ok Hereditart 
Syphilis. Infant two months old. 



1060 



THE SPECIFIC INFECTIOUS DISEASES. 



colour is bright, but gradually becomes of a dusky-red or coppery hue. 
After a little time very fine scales may be seen upon the surface of the 
red macules. The rash comes out slowly, usually requiring from one to 
three, weeks for its full development. It fades gradually, leaving a 
coppery discolouration of the skin, which continues for a long time. The 
duration of the eruption is from three to eight Weeks; less if active 
treatment is employed. 

A papular eruption is rarely seen alone, but is usually associated 
with the macular variety. The papules are of a brownish colour and 
are hard. They are seen most frequently upon the palms and soles. 




Fig. 211. — Early Eruption of Hereditary 
Syphilis. Infant two and one-half months 
old. 




Fig. 212.- 
Foot. 
old. 



-Syphilitic Scaling of the 
From an infant eight weeks 



A squamous eruption is frequently seen upon the palms and soles, but 
very rarely elsewhere. In a few cases this scaliness forms the most dis- 
tinctive feature of the cutaneous lesion (see Fig. 212). 

Fissures and Mucous Patches. — These are among the most diagnostic 
features of early hereditary syphilis. Fissures are most frequently seen 
on the lips and about the anus, but they may occur about the nostrils and 
occasionally elsewhere. The fissures of the lips are really linear ulcers, 
and are distinguished by their persistence in spite of local treatment. 
They are multiple, deep, painful, and bleed easily. After healing, 
these fissures may leave many cicatrices radiating from the mouth, 
the contraction of which produces the so-called " purse-string de- 
formity." 

Mucous patches may develop from fissures, but more frequently from 
papules which are situated in regions where they are exposed to constant 



HEREDITARY SYPHILIS. 



io(n 



moisture and friction. They are very common upon the muco-cutaneouB 
surfaces and wherever the skin is especially thin. They arc most api 
to be seen about the lips, anus, scrotum, and vulva, but they may also be 
found behind the ears, between the toes, in the folds of the groin, axillae, 
or buttocks. They vary from an eighth to half an inch in diameter, are 
whitish in colour, and are raised rather than excavated. 




Fig. 213. 



-A Later Form of Eruption in Hereditary Syphilis. 
Infant eight months old. 



Ulcers may be present upon any of the mucous membranes, fre- 
quently in the mouth or on the genitals; they are seldom symmetrical, 
and while they may be broad they are never deep. 

Haemorrhages. — They are generally associated with the lesions of the 
mucous membranes, especially of the nose. In young infants with severe 
infection, bleeding may occur from the bullous eruption upon the skin, 
or from the fissures at any of the orifices, particularly the mouth and 
anus. Fischl has reported seven cases of multiple haemorrhages in the 
newly born, associated with other symptoms of congenital syphilis. 
Mracek noted haemorrhages in thirty-three per cent of 160 autopsies on 
syphilitic still-born infants or those dying soon after birth. Examination 
of the blood-vessels in some of these cases showed infiltration of their 
walls and narrowing of their lumen. The vascular changes were thought 
to be the cause of the bleeding. 

Nails. — The nails present several peculiarities in syphilitic infants. 
There may be a disease of the matrix resulting in suppuration and ex- 
foliation of the nail; frequently the dorsum is much arched, and the nail 
appears as if it had been pinched by a pair of forceps — i. e., daw-shaped ; 
this is an early symptom of some diagnostic importance. The hair and 
eyebrows frequently fall out completely. This symptom is not usually 
present in very early infancy. 

Pseudo-paralysis.— -This is due to acute epiphysitis, and it may be 
the first symptom of hereditary syphilis to attract attention. It is usu- 



L062 THE SPECIFIC INFECTIOUS DISEASES. 

ally aotieed when the infant is a few weeks old thai one or sometimes 
both anus are not moved, and that the parts are tender when handled. 
The arm is very frequently held in marked inward rotation with the palm 
looking outward, resembling the position in Erb's palsy; hid careful ex- 
amination makes it evident that the loss of power is only apparent, and 
that it is due either to the pain which motion produces or to epiphyseal 
separation. A history will usually he obtained that loss of power did 
not exist at birth, hut developed subsequently. The electrical reactions 
in these cases are normal, and the rapid improvement under mercurial 
treatment is diagnostic. 

The only visceral symptoms of importance are, enlargement of 
the spleen, which is almost invariably present in the active stage of 
hereditary syphilis, and jaundice with or without enlargement of the 
liver. 

Late Hereditary Syphilis. — The symptoms may come on at any 
period during childhood or about the time of puberty, but very rarely 
at a later time than this. They are seen both in those who have had 
the usual symptoms of hereditary syphilis in early infancy, and in others 
where the most careful examination into the history "fails to disclose any 
symptoms whatever of early syphilis. It is fair to assume in such cases 
either that early symptoms were absent or that they were of trivial im- 
portance. 

Late hereditary syphilis shows itself by symptoms which in acquired 
disease would be classed as tertiary. The most characteristic are the 
affections of the teeth, the bones, gummatous deposits in the solid vis- 
cera, the skin, or mucous membranes, the breaking down of which may 
lead to ulceration. 

Teeth. — There are no peculiarities in the first teeth of syphilitic chil- 
dren except their proneness to early decay. They are rather more likely 
to appear early than late. 

The characteristic teeth of syphilis are those of the second set. In 
estimating the diagnostic value of these changes, only the upper central 
incisors are to be relied upon; these are the test teeth. Although changes 
are frequently seen in other teeth, they are not always diagnostic. Typi- 
cal syphilitic teeth, according to Hutchinson, 
have each a single notch in the centre of the 
edge (Fig. 214). The notch is usually shal- 
low and more or less crescentic in shape. The 
enamel is generally deficient in the centre of 

^nson*! Teeth L " (After the notcn , an(1 tlie tootn nere is a P t to be dis ~ 
Foumier.) coloured. The teeth in other cases are vari- 

ously dwarfed and deformed. (See Fig. 
215.) They often taper regularly from the base to the edge, giving rise 
to the term " screw-driver teeth." The teeth are not so flat as the normal 






HEREDITARY SYPHILIS. 



1063 



They are 

each otho 



not properly placed, 
'. They are Beldom 




Fig. 215. — Syphilitic Teeth. Boy 
oi<rht years old; under observation 
several years with various syphi- 
litic manifestations. 

It has already been de- 



incisors, but often pounded and peg-like, 
but incline either toward or away from 
large enough to touch the adjacent 
teeth on both sides. 

Although Hutchinson's teeth may 
generally be taken as conclusive evi- 
dence of syphilis, they are not invari- 
ably so, as Keyes and others have 
shown. It is to be remembered in this 
connection that the absence of changes 
in the teeth is of no importance what- 
ever as evidence that syphilis is not 
present. Hutchinson states that they 
are wanting in more than half the 
cases. 

Bones. — The form of disease which 
is usually seen at this period is an 
osteo-periositis, affecting principally 
the shaft of the long bones and the cranium, 
scribed elsewhere. 

Lymph Nodes. — They are less frequently affected than in adults, and 
in early infancy they are seldom much involved. In most cases after the 
first year there may be found a moderate degree of enlargement of the 
post-cervical and epitrochlear glands, swelling of the latter having con- 
siderable diagnostic value. Under normal conditions the latter can 
scarcely be felt; but in syphilitic children they may be as large as a pea 
or a small bean; sometimes two or three of them can be distinguished. 
They are so rarely enlarged from other constitutional conditions that, 
provided no local cause for the swelling exists, they should always create 
a suspicion of syphilis. The post-cervical glands are frequently affected, 
but are not so diagnostic. The degree of enlargement is rarely great. 
Occasionally there are seen in the neck large masses of swollen lymph 
glands which resemble tuberculous swellings. They are, however, very 
rare. 

Special Senses.— The most frequent affection of the eye in late syph- 
ilis is interstitial keratitis, the close connection of which with hereditary 
syphilis was first pointed out by Hutchinson. It is usually found asso- 
ciated with the typical notched teeth. The diagnostic value of keratitis 
in syphilis is denied by Fournier, who states that, while often syphilitic, 
it is not infrequently due simply to malnutrition. Both eyes are usually 
affected, and in all degrees of severity, from a slight haziness of the 
cornea to complete opacity. However, with an early diagnosis and 
prompt treatment, a marked degree of improvement may be expected 
most cases. 



in 



1004 THE SPECIFIC INFECTIOUS DISEASES. 

Chronic otitis may be a result of the acute process seen in early 
infancy. There is nothing peculiar about the inflammation in these 
cases. A form o\' deafness occurs in older children, which Hutchinson 
states is almost invariably due to syphilis. Its onset is quite sudden, 
without pain. The loss of hearing is apt to be permanent, and if it 
occurs early in childhood it is a cause of deaf-mutism. 

Skin. — The most important of the later manifestations of syphilis 
consists in the formation of subcutaneous gummata. In the early stage 
they are indurated, elastic, of a grayish colour, with red borders. Under 
treatment they disappear quite rapidly by absorption; but when neglected 
they break down, leaving large deep ulcers. These ulcers are quite char- 
acteristic in appearance, but may be confounded with those due to tuber- 
culosis. The syphilitic ulcer has rounded, thickened, indurated borders, 
and a base which is depressed and has the appearance of being scooped 
out. It is sometimes covered by hard crusts and is surrounded by a red 
areola. It leaves a smooth white scar. The most frequent situation 
is upon the face and upper part of the legs or thighs. Tuberculous 
ulcers have usually soft, flat edges, and do not extend so deeply; 
they are more irregular in outline; the cicatrix left is of a purplish 
colour, which becomes red and slowly fades. Tubercle bacilli may be 
found. 

Nose and Palate. — Disease of these parts generally begins as the 
breaking down of gummatous deposits in the mucous membrane. The 
nose may in consequence be the seat of a protracted foetid discharge 
(ozaena) . The disease may take on a destructive form of ulceration which 
is at times phagedenic, and may cause rapid destruction of the nasal car- 
tilages and bones, perforation of the septum, and occasionally of the floor 
of the nasal fossa?. There may be necrosis of the turbinated bones, the 
vomer, or the ethmoid. In the most severe forms the nose may be almost 
destroyed in the course of a few weeks. There may be at the same time 
deep ulceration of the soft palate, leading to perforation. In a young 
person this is almost invariably due to syphilis. In many particulars 
these ulcerations of the nose and palate resemble lupus; they are dis- 
tinguished by the rapidity of their progress, syphilis often doing as 
much damage in weeks as is done by lupus in years. 

Other Symptoms. — Syphilitic disease of the larynx and bronchi is 
rare in childhood. The former may give rise to hoarseness or aphonia 
and occasionally to stenosis ; the latter to a chronic cough and asthmatic 
attacks. There are no characteristic symptoms belonging to syphilis 
of the lungs. The different lesions of the central nervous system which 
may be due to syphilis are all quite rare. The forms have already been 
mentioned, and their symptomatology is discussed in Diseases of the 
Nervous System. 

The only visceral changes which aid much in diagnosis are those of 



HEREDITARY SYPHILIS. 1065 

the liver and spleen. The liver is often enlarged, sometimes to a marked 
degree, and occasionally there is ascites, but very seldom jaundice. 

Enlargement of the spleen is a very frequent symptom — in fact, it is 
almost constant during active syphilitic disease. 1 ha\e several times 
seen it so swollen as to form an abdominal tumour of considerable Bize. 
In one case, in a boy three years old, the spleen extended five inches he- 
low the free border of the ribs, quite to the crest of the ileum. It was 
associated with moderate enlargement of the liver, as i< usually the 
case. 

In addition to the local symptoms of late hereditary syphilis enu- 
merated, there are others of a general character which are quite as im- 
portant. The body is usually undersized; the constitution is delicate, 
and shows but little resistance to all forms of disease; puberty is fre- 
quently delayed, and the development of the breasts and the genital 
organs often imperfect; ancemia is usually present, and the skin has a 
sallow appearance. Mentally, many of these children are somewhat de- 
ficient, and in a few instances they become idiotic, epileptic, or the ob- 
jects of dementia. 

Diagnosis. — The diagnosis of early syphilis in most cases is not diffi- 
cult. The coryza, eruption, labial fissures, mucous patches about the 
anus and genitals, enlarged spleen, and later the general cachexia — all 
unite to form a picture which it is difficult to mistake. In irregular 
cases the diagnosis is easy just in proportion to the number of the fore- 
going symptoms which are present. Special care should be taken not to 
confound the moist papules of simple intertrigo upon the buttocks or 
thighs with those of syphilis. In doubtful cases much assistance may 
be obtained from the discovery of the spirochetal in the external lesions 
and from the Wassermann reaction. 

In late syphilis the following symptoms are the most reliable for 
diagnosis: notching of the teeth, falling in of the bridge of the nose, 
interstitial keratitis, deafness not traceable to ordinary otitis, enlarge- 
ment of the spleen and epitrochlear glands, ulceration of the palate or 
nose, the sabre-like deformity of the tibia, and nodes upon the tibia or 
cranium. There are often found in older children indefinite symptoms 
in regard to which a suspicion of syphilis exists. For such cases the 
AYassermann test is of very great value. 

It becomes at times important to distinguish hereditary from ac- 
quired syphilis. Visceral lesions in acquired syphilis are not common 
and belong to the late period of the disease; in the hereditary form they 
are well-nigh constant and occur early, often being present at birth. 
The acute epiphysitis, sometimes accompanied by pseudo-paralysis 
dom if ever occurs in acquired syphilis, though frequent in the hereditary 
form. Symptoms due to defects in development, like the misshapen fin- 
ger-nails, are seen only in hereditary syphilis. The early symptoms re- 



10(H> THE SPECIFIC [NFECTIOUS DISEASES. 

ferable to the mucou6 membranes and muco-cutaneous surfaces — coryza, 
hoarseness, haemorrhages, labial fissures, etc. — so characteristic of he- 
reditary syphilis, have no place in the acquired form, while the Bingle 
primary lesion sometimes found in the acquired form does not exist in 
the hereditary disease. 

Prognosis. — Generally speaking, the prognosis is worse in infantile 
syphilis than in that of adults. In infancy it is much worse when hered- 
itary than when acquired, for the reason that often the child who is the 
subject of hereditary syphilis has been affeeted by the poison from the 
very beginning of its existence, and this has modified its entire de- 
velopment. 

The results of 206 syphilitic pregnancies obseryed by Jullien (Paris) 
were as follows: Abortion occurred in 36, stillbirths in 8, and 69 chil- 
dren died soon after birth, making a total mortality of 55 per cent ; 
50 were Hying and syphilitic; only 43 liying and in good health. Still 
worse were the results in cases observed by Le Pileur: Of 154 pregnancies 
in syphilitic women, there were 120 abortions or stillbirths. 26 children 
died soon after birth, and only 8 suryived. The statistics of the Found- 
ling Asylum in Moscow for ten years showed that of 2,038 syphilitic in- 
fants the mortality was oyer 70 per cent. 

Such a mortality as that indicated in the above statistics is seen only 
in institutions where little or no preyious treatment has been employed. 
In private practice certainly nothing approaching it occurs. 

In addition to those who die early as the result of syphilitic infection, 
there must be added many whose constitutions are so impaired by syphilis 
that they fall an easy prey in infancy to pneumonia, diarrhoea, or other 
forms of acute disease. The remote effects of syphilis in infancy it is 
hard to estimate; it may exert an injurious influence upon the constitu- 
tion in childhood and eyen throughout the life of the individual. 

The prognosis in an individual case depends upon the age at which 
the symptoms develop, the time when treatment is begun, upon its thor- 
oughness, and upon the surroundings and mode of nourishment of the 
child. The outlook is better the longer after birth the first symptoms 
appear; it is also better in infants who are nursed than in those who 
are artificially fed. 

As compared with syphilis of the adult, relapses are rare, and when 
they occur early they are nearly always the result of insufficient treat- 
ment. If proper early treatment is carried out, the seyere late symptoms 
are rare ; patients are usually, free from all symptoms until six or seyen 
years old, or until near the time of puberty — two periods when they are 
likely to develop. 

The prognosis is better in the later children of syphilitic parents than 
in the earlier ones, provided infection has preceded the birth of all the 
children. This fact illustrates the general tendency of the syphilitic 



HEREDITARY SYPHILIS. 1007 

poison to diminish in virulence as time passes, even without treatment. 
The following instance cited by Bertin well illustrates this point: 

In the first pregnancy, the mother aborted with a dead child at the 
sixtli month; in the second, at the seventh month; in the third, a1 Beven 

and a half months; in the fourth the child was born at term, and lived 
eighteen days; in the fifth it lived six weeks; in the sixth the child lived 
four months, without treatment. 

Prophylaxis. — No infected person should he allowed to marry until 
at least two years have passed after the initial sore, treatment being con- 
tinued meanwhile; nor if there are any active symptoms, no matter bow 
long a time has elapsed since infection. There is no certain! v in any 
case that the child will escape. 

The mother should be treated during her pregnancy: (1) If she is 
syphilitic, whether the disease was acquired at the time of conception 
or subsequently; (2) if the father is known to be suffering from syphilis, 
whether the mother has symptoms or not; (3) if the mother lias ever 
previously shown signs of syphilis, even if she has had no active symptoms 
for a considerable period. In all these conditions if efficient treatment is 
carried on throughout pregnancy there is a strong probability, hut in no 
case a certainty, that the child will escape. The third condition men- 
tioned is the one in which treatment is most likely to be neglected, 
especially if the mother has previously borne a child who was not 
syphilitic. Syphilis, however, shows a strong tendency to reappear and 
become active during pregnancy, even though it has been long quiescent, 
as the following case cited by Diday shows : 

A woman who had lost seven children from syphilis was put under 
treatment during the eighth pregnancy; result — child born healthy, and 
continued so. In the ninth pregnancy treatment was continued with a 
like result; in the tenth pregnancy, no treatment, child syphilitic, dying 
when six months old; in the eleventh pregnancy, treatment repeated, 
child healthy. 

The danger of infection during labour is slight. As the greatest 
danger of infecting a child after birth is from its parents or a wet-nurse, 
syphilitic parents should be duly warned of the danger to their children, 
and especially should be cautioned against kissing them or sleeping in 
the same bed with them. The utmost care should be exercised to pre- 
vent a healthy child from being infected by a syphilitic nurse. A nurse 
should never be accepted without a thorough examination, no matter 
how clear a history may be given. As a syphilitic child in the household 
may be the means of infecting other children, the same precautions 
should be taken as in the case of other contagious diseases. The chief 
danger to other children comes from kissing or from using bottles, spoons, 
or cups which have been infected; as the syphilitic infant is chiefly dan- 
gerous on account of the lesions in the mouth. Trouble most frequently 



1068 THE SPECIFIC INFECTIOUS DISEASES. 

occurs because of ignorance regarding the nature of the disease. It is 
possible for a syphilitic child to nurse a healthy woman without com- 
municating syphilis, if the child's mouth is treated and the nipple not 
allowed to become fissured; but it is an experiment which should never 
he tried. 

Treatment. — This should always be begun as soon as the first positive 
symptoms of syphilis appear. Under certain circumstances it may be 
advisable not to wait for symptoms; as, for example, when both parents 
have recently suffered from active symptoms, when previous children 
have died soon after birth, or when, with marked symptoms in the par- 
ents, the child exhibits the cachexia of syphilis, but no definite local 
symptoms. Such anticipatory treatment need not be continued longer 
than six weeks unless symptoms appear. 

The indirect treatment, designed to reach the child through the 
mother's milk, has fallen into deserved disuse, as it is very uncertain 
and altogether unsatisfactory. 

Mercury is as much a specific fcr hereditary as for acquired syphilis. 
There are many wa} r s of introducing it into the system : it may be given 
by inunctions, by the mouth, by fumigations, by baths, or hypodermic- 
ally. In most cases inunction is the manner to be preferred in young 
infants. Gr. x of mercurial ointment, diluted with the same amount of 
vaseline, may be rubbed daily into the palms, soles, axillae, or the inner 
surface of the thighs. It is advisable to change the place of inunction 
from day to day; and if this is done, it is extremely rare that erythema 
is produced. If for any reason inunctions are objectionable, as they 
may be when the family are to be kept in ignorance of the treatment, 
either the gray powder or the bichloride may be given by the mouth. 
The usual dose of the gray powder should be gr. \ four times a day; 
that of the bichloride gr. ^ four times a day, always well diluted. It 
is rare that larger doses are advisable. When the symptoms are urgent, 
it is often best to substitute calomel for a few weeks, as the system can 
usually be brought more rapidly under the influence of mercury by 
this than by the other preparations mentioned; gr. T V four times a day 
is the usual dose required. Other methods of administration and other 
preparations offer no advantages, and have some very obvious dis- 
advantages. 

The iodide of potassium is to be used, either alone or in combination 
with mercury, whenever such lesions exist as are classed among adults 
as tertiary. This includes all the late manifestations, and the earlier 
ones whenever the bones or viscera are affected. The iodide is usually 
well borne by children, and may be given in almost any desired dosage. 
In infancy it is rare that more than twenty grains daily are required, but 
in older children the necessary amount may be from one to two drachms 
daily. It should always be given largely diluted. 



HEREDITARY SYPHILIS. 1069 

The duration of mercurial treatment should be at least one year. Tin- 
doses during the last six months may be reduced to one-half or one-third 
those employed while active symptoms are present. Treatment should 
be longer than a year if symptoms exist. It is often better not to give 
the mercury continuously, but with short periods of intermission. 

Ehrlich's salvarsan is quite as efficacious in infants as in older pa- 
tients. Experience has shown that a single dose does not cure Byphilis. 
A repetition is necessary; two or more injections should be given, and the 
best results are obtained when it is combined with the mercurial treat- 
ment. In older children the intravenous method of administration is 
to be preferred; an alkaline solution should be employed. For a child 
of five years the dose is gramme . 1 or gramme . 2. In infancy the dif- 
ficulties in the way of intravenous administration are so great that the 
remedy must in most cases be injected into the muscles. For this pur- 
pose suspension in a bland oil, such as benzoinol, is preferable to solu- 
tions, or aqueous suspensions. The best site for injection is the outer 
part of the buttock high enough to avoid the sciatic nerve. Before re- 
moving the needle from the tissues, a few drops of saline solution should 
be injected through it so as to leave none of the salvarsan in the sub- 
cutaneous tissue as the needle is withdrawn; otherwise sloughing may 
result. The dose for an infant is gramme 0.03 to gramme 0.05. 

The tonic treatment of syphilis is important and should not be neg- 
lected. After specific treatment has been carried on for a time, particu- 
larly if rapidly pushed, the child often becomes anaemic, and suffers 
greatly from general malnutrition. Under such circumstances it is 
often wise to discontinue mercury altogether for a time, or at least to 
reduce the dose very much, and administer cod-liver oil, iron, and other 
tonics. Such a change is frequently found to act most beneficially, even 
when lesions are present, which perhaps have been very little or not at 
all affected by the specific remedies employed. A judicious combination 
of specific and tonic treatment is required in every case, whether the 
remedies are given simultaneously or alternately. 

Local Treatment. — Ulcerative lesions of the skin require cleanliness, 
dusting with calomel or iodoform, or bathing with the black wash. Mu- 
cous patches should be dusted with equal parts of calomel and bismuth. 
Fissures and ulcers of the mucous membranes should be treated by nitrate 
of silver. Phagedenic ulcers of the palate or nose should be cauterised 
with nitric acid or the acid nitrate of mercury. The late syphilitic ulcers 
of the skin, due to the breaking down of gummata, should be treated 
aseptically. 



1070 THE SPECIFIC INFECTIOUS DISEASES. 



CHAPTER XII. 

INFLUENZA. 

{La grippe.) 

Influenza is an infectious, communicable disease, which is now 
generally admitted to be due to the bacillus described by Pfeiffer in 1892. 
It is serious in children chiefly from its tendency to complications of 
the respiratory tract. 

Etiology. — The influenza bacillus is found in the secretions of the 
lower air-passages, less frequently in those of the rhino-pharynx, oc- 
casionally in the discharge of acute otitis, rarely in empyema and men- 
ingitis. In meningitis the organism is generally found in the blood, 
i. e., it is a part of a general influenza septicaemia. In the sputum its 
presence can be demonstrated with certainty only by cultures upon blood 
agar. In acute cases it may disappear very early; in protracted cases 
its presence can often be demonstrated for weeks or even months. Be- 
sides the bacillus of Pfeiffer, there are usually found in patients suffer- 
ing from influenza, the pneumococcus, the staphylococcus aureus, and 
the streptococcus, either separately or in combination. It is often dif- 
ficult in these mixed infections to tell what part the different organisms 
play in the pathological process. 

Influenza is highly contagious and is almost invariably transmitted 
by direct contact. In New York the disease attracted little attention 
until the great epidemic of 1891, since which time it has regularly been 
seen every winter season with greater or less severity. It disappears 
with the advent of warm weather. Epidemics prevail chiefly in winter 
and spring. All ages are liable to the disease, infants under one year 
especially so. 

The period of incubation is uncertain. It is usually short, generally 
from one to seven days. Little if any immunity seems to be afforded 
by one attack; recurrences and second attacks are not uncommon in the 
same epidemic. 

Lesions. — There are no characteristic lesions of influenza; those 
which are most frequently found are due to inflammations of the. respir- 
atory tract which differ little from the same inflammations when due 
to other organisms. In some cases the upper respiratory tract is alone 
or chiefly involved. These cases are frequently complicated by otitis, 
although the influenza bacillus is not often found in the aural discharge. 
In other cases only the lower respiratory tract is involved, the process 
usually spreading in infancy to the lungs, resulting in broncho-pneu- 
monia. 

Symptoms. — The symptoms of influenza are due to the systemic 
effects of a general infection, and to certain local inflammations which 



INFLUENZA. 



1071 



may be regarded as complications. The two classes of symptoms — the 
general and the local ones — are found in all possible combinations. 

The milder attacks last from two to five days, occasionally a week. 
The onset is usually abrupt, with chilliness, muscular pain-, and some- 
times vomiting. The temperature ranges from 101° to 10;*° P. Even 
though the fever is not high, the prostration is considerable, and chil- 
dren are often ill enough to remain in bed for several days. The usual 
general symptoms which accompany fever are present. Convalescence 
is frequently protracted, and it may be three or four weeks before the 
general health is regained. Often there is in addition a mild coryza 
at the outset and a slight but persistent cough. 

More severe attacks are characterised by higher temperature, but 
only moderate prostration. They often resemble cases of pneumonia, 



Makch 13 




Fig. 216. — Temperature Chart of Uncomplicated Influenza. Infant fourteen 
months old. No local signs of disease; repeated blood examinations for malaria 
negative; the wide fluctuations of the temperature independent of therapeutic meas- 
ures. Prompt cessation of fever on removal from the city. 



except that the local symptoms and physical signs in the chest are want- 
ing. The onset is usually abrupt with vomiting and headache, rarely 
with convulsions. The temperature ranges from 100° to 10(5. 5° P. It 
seldom remains steadily high, but fluctuates .widely, often being sub- 
normal. I have repeatedly seen a temperature of over 10(5° F. in 
uncomplicated influenza. Marked nervous symptoms are sometimes 
present; there may be headache, stupor, and convulsions— symptoms 



1072 



THE SPECIFIC INFECTIOUS DISEASES. 



somewhat suggesting meningitis, but not so continuous as in that dis- 
ease. More frequently, however, one is struck by the disproportion 
existing between the high temperature and the general symptoms. The 
course of the temperature is unlike that seen in any other disease. It 
is high and fluctuates widely and irregularly without apparent reason. 
Variations of six or seven degrees in the course of a few hours are very 
often seen. Often, although the temperature rises every day to 104° or 
even 105° F., the patient may seem to be scarcely ill at all. The usual 
duration of these severe attacks is from five to ten days; but even when 
no complication develops symptoms may last much longer, sometimes 
until a change of climate is made. (See Fig. 216.) Although the symp- 
toms are very alarming, except in young infants, the attacks are seldom 
fatal unless pneumonia develops. 

Besides these general manifestations the sjnuptoms of acute rhino- 
pharyngitis may be present. The whole pharynx may be the seat of an 
acute, erythematous blush, or the mucous membrane may present a gran- 
ular or spongy appearance. Occasionally there is follicular tonsillitis. 
These catarrhal symptoms may last for several days and gradually subside. 
A moderate amount of inflammation of the mucous membrane of the 
larynx, trachea, and large bronchi occurs in most of the cases of influ- 
enza. In the more severe forms, 
broncho-pneumonia often develops. 
Sometimes the pulmonary symp- 
toms do not appear for two or three 
days, or even a week; at other times 
they are coincident w r ith the devel- 
opment of the fever and other con- 
stitutional symptoms, and, except 
for the prevalence of influenza, this 
would not be considered a factor in 
these cases. 

The broncho-pneumonia compli- 
cating influenza may not differ es- 
sentially from the ordinary types, 
except that the proportion of cases 
which do not go on to the develop- 
ment of areas of consolidation is 
larger than is seen under most other 
conditions. If lobar pneumonia de- 
velops, it frequently runs its regular 
course. But besides these two vari- 
eties of pneumonia, quite a large number of cases of an irregular type are 
seen with influenza. These are often of short duration, but accompanied 
by extremely high temperature (Fig. 217). 




Fig. 217. — Acute Broncho-pneumonia, 
Abortive Type, Complicating In- 
fluenza in an Infant Six Months 
Old. The entire left lung posteriorly 
was involved. 



INFLUENZA. } 973 

Vomiting and diarrhoea are frequent at the beginning of influenza, 
and in some cases, especially in infants, they may continue throughout 
the attack. 

Protracted and recurring attacks of influenza are exceedingly com- 
mon and the influenza bacillus may be demonstrated for months in the 
secretions of such patients. The protracted cases in my experience have 
almost invariably been preceded by a well-defined acute attack, after 
which there is improvement but not recovery, and an irregular low fever 
follows, which may drag on indefinitely or there may recur, at intervale 
of a few days or weeks, periods of very high temperature sometimes 
accompanied by pulmonary symptoms and signs and sometimes not. 
The cases are often called malaria, or chronic intestinal poisoning, and 
not infrequently tuberculosis is suspected; but the special features of 
all these diseases are wanting. In the cases I have seen the symptoms 
have been controlled by change of climate, but without this they have 
not infrequently continued until the following warm season. The rare 
cases of influenza in which the organisms are found in the blood are 
characterised by severe constitutional symptoms. They usually prove 
fatal either from the development of extensive pneumonia or from menin- 
gitis. The physical signs in influenza pneumonia and the nervous symp- 
toms in influenza meningitis are not characteristic. Occasionally with 
severe infections abscesses may develop in the large joints. 

Complications and Sequelae. — The most frequent complications are — 
pneumonia, otitis, and adenitis. Cutaneous eruptions are not infrequent, 
and are often very puzzling. There may be a general urticaria, or an 
erythema which sometimes simulates measles, but more frequently 
scarlet fever. In most of the cases with high temperature the urine con- 
tains albumin, and acute nephritis is not infrequent. I have seen three cases 
of haemorrhagic nephritis in a single season. All recovered promptly. 
The nervous sequelae of adults — mental disturbances, multiple neuritis, 
etc. — are extremely rare in childhood, although they have been observed. 
One of the most frequent sequelae is anaemia; this may be very severe. 
Following the inflammation of the mucous membranes, there may he 
chronic enlargement of the cervical lymph glands. Attacks of influenza 
bear the same relation to the development of tuberculosis as do those of 
measles. 

Convalescence after influenza is usually very slow, and it is often 
many months before the full effects of a severe attack have disappeared. 
For a long time the mucous membranes are in an extremely sensitive con- 
dition. Eelapses are often brought about by slight exposure before the 
symptoms have quite disappeared, and I have seen them occur from a 
single outing. 

Diagnosis. — The ordinary head colds even when severe and epidemic 
are verv rarely due to influenza infection. There are certain features 



1074 



THE SPECIFIC INFECTIOUS DISEASES. 



which distinguish influenza infections of the lower respiratory tract from 
those due to other causes: these arc a tendency to chronicity, to relapses, 
and to recurrences. In the febrile eases a very high and widely fluctuat- 
ing temperature accompanied by few constitutional symptoms is always 
suggestive in the winter season. Eecurring attacks of pneumonia sep- 
arated by an interval of days or weeks with partial or apparently complete 
recovery are very often due to influenza. 

Influenza can be differentiated from the catarrhal inflammations due 
to other causes only by cultures upon blood agar. These should be made 
from the bronchial secretion which is obtained as in cases of tuberculosis 
(q. v.). A culture made from the pharyngeal secretion is not conclusive. 
Influenza may be confounded with malaria or cerebro-spinal meningitis; 
from both of these it is distinguished by the methods of diagnosis used 




Fig. 218. — Influenza-bronchitis; Double Otitis; Late Broncho-pneumonia; Au- 
topsy. Infant, nine months old, admitted with influenza-bronchitis; double para- 
centesis fourth day, repeated on tenth day; the left ear opened again on twelfth and 
twenty-fourth days. The only signs in the chest were those of bronchitis until the 
eighteenth day, then broncho-pneumonia which persisted until death. On account 
of the wide fluctuations in temperature from the eighth to the eighteenth day, mas- 
toiditis and sinus thrombosis suspected. Operation not permitted, partly because 
of the child's poor condition, but chiefly because the bacillus influenzae was con- 
stantly present in the bronchial secretion and this was regarded as a sufficient ex- 
planation of the temperature. Autopsy. — Moderate broncho-pneumonia; cultures 
from the lungs showed the influenza bacillus and pneumococcus. Careful examina- 
tion of the mastoid and sinus showed no trace of disease. 



to identify these diseases. Especial difficulties of diagnosis often exist 
when influenza is complicated by otitis. Although the operation of 
paracentesis may relieve the local condition it does not arrest the general 
infection, and the characteristic fluctuations of the temperature belong- 
ing to influenza may continue. Under such circumstances the diagnosis 
of mastoiditis or sinus thrombosis is often erroneously made. (See 
Fig. 218.) 

Prognosis. — Uncomplicated cases are seldom fatal, except in infants 
under six months old; and even though the temperature is very high and 
the symptoms severe, recovery may be predicted as long as there is no 
evidence of serious complications. The prognosis of the pneumonia of 
influenza is rather worse than that of simple broncho-pneumonia. In a 



MALARIA. 1075 

word, influenza is particularly serious in the very young, or when there 

are pulmonary complications, but rarely otherwise. 

Treatment. — The communicability of the disease makes it desirable 
that cases of influenza should be isolated whenever practicable, and par- 
ticularly that delicate children, or those prone to pulmonary di 
should not be exposed. The fumigation of apartments after attacks 
should be regularly practised, preferably with formalin gas; this with 
isolation will do much to control house epidemics. 

As there is no specific for influenza, the indications are to sustain 
the patient, to make him comfortable during the attack, and to prevent 
so far as possible the occurrence of complications. Every child with 
influenza should be put to bed and kept there during acute symptoms. 
At the outset the bowels should be opened by castor oil or calomel. A 
very high temperature should be relieved by cold sponging or the cold 
pack, precisely as in pneumonia, but large doses of antipyretic drugs 
are to be avoided. The nervous symptoms — restlessness, pain, headache, 
and other disturbances — are best controlled by phenacetine in combina- 
tion with codeine — e. g., to a child of one year, phenacetine gr. j, codeine 
gr. ^ every three or four hours. Double the dose may be given to a 
child of two years. Stimulants are required whenever the pulse shows 
signs of weakness. They should be given according to the same rules as 
in pneumonia. . 

The cough which so often persists after influenza is best controlled 
by cod-liver oil and creosote, used as after acute bronchitis. With per- 
sistent bronchitis which resists ordinary remedies, a patient should be 
sent to a warm, dry climate. The complications of influenza are to be 
treated as they arise, in the same manner as when they occur under 
other conditions. In all cases careful feeding in accordance with tin- 
general rules laid down for feeding in acute diseases, good nursing, and 
care to avoid exposure during convalescence, are essentials in treatment. 
One should be particularly anxious about patients who have a strong 
tendency to tuberculosis, and such cases should be watched with the great- 
est care. 

In prolonged or constantly recurring attacks nothing is of much 
avail except a removal to a warm climate. If this is impossible, a young 
or delicate child should be kept indoors during the cold season, but fre- 
quently moved from one apartment to another. 



CHAPTER XIII. 
MALARIA. 



Malaria is an infectious disease due to the presence in the blood of 
a specific organism often called the Plasmodium, but more exactly the 



1070 THE SPECIFIC INFECTIOUS DISEASES. 

hofmatocytozoon malaria. It manifests itself in children by the ordinary 
acute febrile attacks which are seen in adults and by chronic malarial 
poisoning. Both of these forms may present certain peculiar symptoms 
dependent upon the age of the patient. 

Etiology. — The malarial organism was discovered by Laveran in 1881 ; 
it is a parasite of the blood and belongs to the group of protozoa. It is 
now well established that the parasite enters the blood through the bite 
of certain forms of mosquito, those belonging to the genus Anopheles, 
and probably in no other way. For this knowledge we are indebted 
chiefly to the work of Eonald Ross, in India, in 1897. For a general 
discussion of the malarial parasite, its methods of staining, etc., the 
reader is referred to works on clinical medicine. 

Malaria affects all ages, even the newly-born infant. "We must accept 
with some allowance the statements made by the older writers upon the 
subject of intra-uterine infection, but in the following case occurring in 
the practice of my former associate, Dr. Crandall, there seems little 
doubt that the disease was contracted in utero: For ten days before de- 
livery the mother had suffered from a tertian intermittent of moderate 
severity. Eighteen hours after birth the child was noticed to have cold 
hands and feet, blue lips and nails, and a pinched face. These symptoms 
lasted about half an hour and were followed by a distinct fever. Upon 
the following day the paroxysm was repeated. Examination of the blood 
of both mother and child revealed the malarial organisms in both cases. 

Malaria is more frequently overlooked in young children than in later 
life, from the fact that its forms are more irregular, and this has led to 
the belief that young children are less liable than adults to the disease. 
I believe, however, the opposite to be the case. In a large number of in- 
stances where families have been exposed to malarial poisoning I have 
noted that the young children were frequently the first to show the 
symptoms of the disease. 

Malaria is an endemic disease prevailing in certain localities. Exact 
knowledge regarding the mode of infection has cleared up many obscure 
points in its etiology. The role of the mosquito explains the greater 
liability to contract malaria after sunset and • during the night, the 
danger from stagnant ponds and pools of water, the peculiar suscepti- 
bility of infants and young children, and the greater frequency of the 
disease in the spring and summer. Malarial attacks may, however, 
occur at any season, since the organism may be latent in the body for 
an indefinite time; how long it is impossible to say, but there seems 
to be conclusive proof that it may be for many months. Attacks of 
malaria very often occur when the general health has been reduced by 
some other cause, particularly by disturbances of digestion. 

lesions. — Opportunities for a study of the peculiarities of the lesions 
of malaria in children are infrequent, especially in New York, as fatal 



MALARIA. 



1077 



cases are extremely rare. I have myself seen but two. As observe. I by 
others, the lesions do not differ in any marked way from those of 1 1n- 
adult form of the disease. The most important changes are the destruc- 
tion of the red corpuscles of the blood, enlargement, and in chronic 
cases hyperplasia with pigmentation of the spleen; Less frequently pig- 
mentation of the liver, kidneys, and brain. Pneumonia and gastro- 
enteritis are occasional complications. 



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Fig. 219. — Typical Malarial Temperature, Quotidian Type, in a Boy Six Years 
Old. Each paroxysm preceded by a chill. It will be noticed that the temperature 
rose higher with each succeeding paroxysm; X marks the time when quinine was begun. 

Symptoms. — The clinical forms of malarial fever in children from six 
to ten years old, do not differ essentially from the same disease in adults. 
Both intermittent and remittent forms occur, the former being the type 
usually seen. Of the different varieties of intermittent fever, the quo- 
tidian (Fig. 219) is the most common, although the tertian (Fig. B20) 
is fairly frequent, but in this locality the quartan is extremely rare. The 
stages of the paroxysm are generally well marked. The cold stage begins 
with a chill or vomiting, with headache, lassitude, and general pains. 



107S 



THE SPECIFIC INFECTIOUS DISEASES. 



The hot stage is usually characterised by a higher temperature than in 
adults, and this is followed by the sweating stage, which is generally 
marked. The paroxysm may he repeated every day or every other day 
until controlled by quinine, or the stages may become less and less dis- 



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Fig. 220.— Typical Malarial Temperature, Tertian Type, in a Boy Five Years Old. 
Onset with vomiting and drowsiness, but no chill. This was an anticipating inter- 
mittent, the first paroxysm occurring at 3 p.m., the second at 12 M., the third at 10 
a.m. ; X marks the time when quinine was begun. 



tinct as the disease progresses until a more or less remittent type of fever 
develops. Less frequently the fever is remittent from the beginning and 
the constitutional symptoms are of greater severity. In this form there 
is marked prostration, the tongue is thickly coated, there are often ten- 
derness and pain in the region of the liver, and occasionally there is 
slight jaundice. 

In infants and very young children peculiar types of malaria are 
seen. A well-marked intermittent fever with distinct stages is often 
absent, many cases assuming more of a remittent type or an irregular 
form of intermittent (Fig. 221). The onset is usually abrupt with vom- 
iting, a well-marked chill being rare. Malarial chills are not often wit- 



MALARIA. 



107<) 



nessed in children under five years old. They are replaced in infants h\ 
cold hands and feet, blue lips and nails, sometimes slight general cyano- 
sis, pallor, drowsiness, and prostration. Vomiting has been present in 
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ushered in by convulsions. 

The fever is relatively higher than in adults, rising rapidly to 10 1° or 
105° F., occasionally to 106° or 106.5° F. This continues from four to 
twelve hours and gradually falls, usually to normal. The other constitu- 
tional symptoms of the febrile stage are much less severe than in most 
diseases with the same elevation of temperature. The sweating stage- 
is only slightly marked and is often absent altogether. Willi the fail 



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Tig. 221. — An Irregular Malarial Temperature in a Child Nine Months Old. 
The paroxysm on the fourth day was accompanied by an attack of acute pulmonary 
congestion which came near being fatal; X marks the time when quinine was begun. 
Although the course of the temperature is irregular, it touched the normal line both 
on the second and fourth days. 

in the temperature there is a gradual subsidence of all the other symp- 
toms of the febrile stage. 

After the first paroxysm the patient may be quite well for several 
hours or even for a day, when the second paroxysm occurs. This is gen- 
erally not so well marked as the first one, the third may be even I 
and the case may resemble more and more one of continuous fever with 
wide oscillations in the temperature. In some cases it is remittent at 



10S0 THE SPECIFIC INFECTIOUS DISEASES. 

first and later becomes intermittent, but it is very rare under any cir- 
cumstances that the temperature does not touch the normal point at some 
time in the twenty-four hours. In infants the quotidian has been in my 
experience very much more frequent than any other type, the tertian 
being uncommon and the quartan almost unknown. 

Enlargement of the spleen is present in the great majority of cases, 
and usually to a sufficient degree to be readily appreciated by examina- 
tion. The most satisfactory method of examination is by palpation. 
A spleen which can be easily felt below the ribs (except in the rare 
eases in which the organ is displaced downward by some condition in 
the thorax) is enlarged. When it is not sufficiently enlarged to be 
readily felt by a practised observer under favourable conditions for ex- 
amination, it is not large enough to be of any diagnostic importance. 
None of the other symptoms occurring in malarial fever are charac- 
teristic ; they are quite similar to those which are seen in almost all 
febrile attacks. They are anorexia, coated tongue, constipation, and 
restlessness. 

Masked or Irregular Forms of Malaria. — These are quite frequent in 
young children, and are due to the presence of certain special or uncom- 
mon symptoms which may readily lead to a mistake in diagnosis. They 
are more often seen than cases of true malarial cachexia. 

Among the most frequent of the irregular forms are those relating 
to the nervous system. Headache is exceedingly common and is usually 
frontal. When severe and associated with continuous drowsiness, vomit- 
ing, and constipation, it may lead to a strong suspicion of tuberculous 
meningitis. Vertigo is not a frequent symptom, but it is sometimes very 
prominent. Pains in various parts of the body are very common. A 
sharp, severe pain at the epigastrium is frequent at the beginning of a 
paroxysm. It is often associated with tenderness, but has no relation to 
meals. Less frequently, pain is localised in the region of the spleen 
or liver. Trifacial neuralgia of malarial origin is rare in childhood. 
Aching or dragging pains in the muscles of the lower extremities are 
frequent symptoms during acute attacks, but they are of short duration, 
disappearing with the fever. They are to be distinguished from the 
acute lancinating pains of multiple neuritis, which is occasionally seen 
as a result of malarial poisoning. I have seen the latter in young chil- 
dren in three cases, and it has been observed by others. The pain is 
accompanied by tenderness of the muscles and nerve trunks, and by loss 
of power, which is usually partial. Spasmodic torticollis I have seen in 
eight cases, in which the condition seemed very clearly to depend upon 
malaria. 

Accompanying the paroxysm of malaria there is occasionally seen, 
more often in infants than in older children, acute pulmonary congestion 
(Fig. 221), which may give rise to obscure and often very alarming 



MALARIA. 1081 

symptoms. There is an acute onset with vomiting and prostration, high 
temperature, cough, rapid respiration, and often slight cyanosis. On ex- 
amination of the chest there is found feeble or rude respiration over one 
lung, or over both lungs behind, and sometimes coarse moist rales ; these 
signs and symptoms may disappear in the course of a few hours with the 
fall in temperature, to return with the next paroxysm, or if quinine is 
given they may disappear entirely. 1 This group of symptoms lias some- 
times led to the mistaken opinion that the disease was pneumonia, which 
had been aborted by the administration of quinine. 

Subacute or Chronic Forms of Malaria. — The most constant symp- 
toms are anaemia, enlargement of the spleen, and slight fever. The 
anaemia is usually marked, often being extreme. The enlargement of the 
spleen is distinct, easily made out by palpation, and sometimes is very 
great. The fever is often so slight as to be discovered only when the 
temperature is taken five or six times in the twenty-four hours. The 
other symptoms are of a very indefinite character; there may be slight 
oedema of the lower extremities, general muscular weakness, so that the 
child is easily fatigued, loss of appetite, coated tongue, constipation, head- 
ache, muscular pains, and often cough from a slight bronchitis. These 
symptoms may depend upon many conditions other than malaria, even 
when they are seen in a malarial district. The only positive evidence of 
malaria in such cases is the presence of the malarial organisms in the 
blood. Even the swollen spleen, anaemia, and slight fever, which are 
often looked upon as diagnostic, may be present in cases of anaemia with 
which malaria has nothing whatever to do. 

1 The following case is a good example of this condition in its more severe form, 
and illustrates the difficulties in the diagnosis of malaria in infancy: A fairly nour- 
ished child, nine months old, who had been under observation in an institution for 
two weeks, was suddenly taken with vomiting and fever (Fig. 221). A cathartic was 
followed by a large undigested stool, and as the temperature then fell to normal, the 
attack was regarded as one of indigestion. On the third day the temperature was 
again high and accompanied by cough; coarse rales were found throughout the chest, 
and fine rales at the right base; it was then thought that pneumonia was developing. 
On the fourth day all the symptoms were so much improved that the infant was 
regarded as convalescent. At 6 p. m. the temperature was normal, and the infant went to 
sleep quietly. At 9.30 p.m. he awoke with a temperature of 104° F., extreme restlessness, 
and marked dyspnoea. In half an hour his symptoms had increased to a point whore he 
seemed likely to die. He became cyanotic, the respirations were of a panting char- 
acter and rose nearly to one hundred a minute, and he coughed w r ith almost every 
breath; the pulse was scarcely perceptible. The severe symptoms continued for about 
an hour, then passed away gradually, and at the end of two and a half hours they 
had completely disappeared, and the child was in a quiet sleep which continued until 
morning. Malaria was now suspected, and the diagnosis established by the discovery 
of the Plasmodium in the blood. The spleen was at this time much enlarged; the 
signs in the chest were those only of bronchitis of the large tubes. Quinine WM 
given in full doses, and immediately controlled the temperature and the pulmonary 
symptoms. 



1082 THE SPECIFIC INFECTIOUS DISEASES. . 

Diagnosis. — The positive diagnosis of malaria rests upon the demon- 
stration of the malarial organisms in the blood. They will be found in 
nearly all the cases provided a careful examination is made a few hours 
before the paroxysm, and also that no quinine has been administered. 
When their number is small they may be missed at the height of the 
fever, although they may readily be found just before the temperature 
begins to rise. While a po3itive result is conclusive, a negative one is not 
always so because of the impossibility of fulfilling all the above condi- 
tions. This fact and lack of experience in blood examinations make it 
necessary for a large part of the profession to make the diagnosis by the 
other symptoms. These, in the order of their importance, I would place 
as follows: Prompt curability (especially in cases of fever) by quinine; 
distinct periodicity in the symptoms; enlargement of the spleen; and a 
history of an exposure in a district known to be malarial. Particular 
importance is to be attached to the therapeutic test. Eecent experience 
emphasises more and more strongly the fact that quinine has very little 
influence upon fevers which are not malarial, and, conversely, that a fever 
immediately and permanently controlled by quinine is pretty certain to 
be malarial. 

The cachexia and course of the temperature in septicaemia, pyaemia, 
broncho-pneumonia, tuberculosis, and empyema, may cause them to be 
mistaken for malaria. The fever and recurring chills of pyelitis are 
often attributed to malaria; as are also the heaviness, lethargy, head- 
ache, coated tongue, and slight fever of chronic intestinal indigestion. 
Many conditions accompanied by an enlarged spleen may be confounded 
with malaria, especially simple anaemia, leukaemia, rickets, and syphilis. 
While malaria may be multiform in its manifestations, the physician can 
fall into no more serious error than to regard all ailments with obscure 
or indefinite symptoms as malarial, neglecting careful physical and blood 
examinations, by which means alone an accurate diagnosis is reached. 

Prognosis. — Although it is seldom fatal in itself, an attack of malaria 
in a young child may so undermine his constitution that he may suc- 
cumb to some other acute disease. Cases are often difficult to cure 
while the patient remains in the malarial districts, and when frequent 
reinfection occurs. Under other circumstances and with proper treat- 
ment the prognosis of malaria is good. 

Treatment. — Prophylaxis. — More exact knowledge regarding the eti- 
ology of malaria makes it possible for much to be done in the way of 
prevention. Besides the general measures proposed for the extermina- 
tion of the mosquitoes concerned, emphasis should be laid upon the neces- 
sity, in the case of young children, of protecting them against the bites 
of mosquitoes in localities which are or which may possibly be malarial. 
This can be done by a more thorough use of mosquito netting and by 
using upon exposed parts of the body lotions or ointments containing 



MALARIA. Ids;; 

menthol, pennyroyal, turpentine, or other substances which keep these 
pests away. The general treatment is symptomatic, and is to be con- 
ducted as in all acute febrile diseases. In the cold stage. Btimulanl 
hot bath may be required; in the hot stage, ice to the head and frequent 
sponging. The bowels in all cases should be freely opened, preferably 
by calomel. 

Methods of Administration of Quinine. — For infants my own }»: 
ence is to give the bisulphate in an aqueous solution, one or two grains 
to the teaspoonful, according to the age of the patient. Most infants 
take such a solution with less difficulty and vomit it less frequently than 
the combinations with the various vehicles supposed to cover its taste 
In the event of failure by this method, the same solution may be given per 
rectum through a catheter. It should then be more largely diluted with 
some bland fluid such as gruel, and in double the dose. This is necee 
not only because absorption is less certain and complete, but also be- 
cause a rectal dose can seldom be repeated oftener than every five or 
six hours. There is sometimes an advantage in giving part of the 
quinine by the mouth and part of it by the rectum : should both fail it 
may be given hypodermically. For this purpose the bimuriate of quinine 
and urea, the hydrobromate, or the bisulphate may be used. All are more 
or less irritating and there usually follows some induration at the site 
of the injection, which may last a long time. While the hypodermic use 
of quinine is sometimes invaluable it should not be employed in infants 
except in serious attacks and when the diagnosis has been established. 
In a number of instances both in hospitals and private practice I have 
seen sloughing follow the use of nearly all the preparations generally 
employed. The occurrence of abscess points to infection at the time 
of injection; but necrosis I believe may be due simply to the irritation of 
the quinine upon tissues having a lowered vitality, as in the case of young 
or delicate infants. I have seen this happen when the strictest precau- 
tions against infection were observed. The frequent repetition of the 
hypodermic injections should be avoided; in most cases, one or two good 
doses are sufficient, the effect being continued by quinine given by other 
methods. 

For children from two to seven years old the taste of quinine must 
be concealed. An aqueous solution of the bisulphate may be mixed with 
the syrup of sarsaparilla, orange, or verba santa : or the sulphate may be 
given in suspension in one of the same vehicles, the mixture being made 
just before the dose is taken ; otherwise the partial solution of the drug 
will render the whole dose exceedingly bitter. When the dose required is 
not large, as in the milder cases, the lozenges of the tannate of quinine 
combined with chocolate answer the purpose admirably, for these are so 
nearly tasteless that children will take them without difficulty. Each 
lozenge usually contains one grain of the tannate, which is equivalent to 



1084 THE SPECIFIC INFECTIOUS DISEASES. 

about one-third of a grain of the sulphate of quinine. A similar lozenge 
containing one grain of the sulphate may be made, which is often taken 
by children without the slightest objection. The bisulphate may be given 
in solution by the rectum, or, better, at this age, in the form of supposi- 
tories ; but, as in infancy, with very urgent symptoms, it is better to resort 
at once to the hypodermic method in case of failure by the stomach. 

For children over seven years old, the same methods of administra- 
tion may usually be employed as in adults. It is always preferable to 
give quinine in solution, or if not so, in capsule, but not in pill form. 

In a case with well-marked paroxysms the quinine should if possible 
be given in the interval, with the largest dose about four hours before 
the expected paroxysm. With infants this plan is sometimes imprac- 
ticable, as frequent small doses are usually better borne by the stomach 
than a few large ones. In them also vomiting seems less likely to occur 
when it is given on an empty stomach. For this reason it is advantageous 
to give the drug at regular two- or three-hour intervals during the night, 
and omit all medication during the day. 

Dosage. — Eelatively much larger doses of quinine are required for 
young children than for adults. Except for its tendency to disturb the 
stomach, quinine is borne remarkably well by little patients. Generally 
too small doses are given. An infant of a year with a sharp attack of 
malarial fever will usually require from eight to twelve grains of the 
sulphate (ten to fourteen grains of the bisulphate) daily. Occasionally 
I have found it necessary to give double the quantity referred to, and I 
have seen no unpleasant cerebral symptoms. It is useless to expect to 
control an acute attack of malaria by such doses as one grain three or 
four times a day. Children from five to ten years old require almost as 
large doses as do adults. None of the substitutes for quinine are to be 
relied upon in acute cases. 

In chronic cases, arsenic and iron are usually required in combination 
with smaller doses of the quinine than those mentioned. For children 
over seven years old, Warburg's tincture may be employed. In most 
chronic cases a cure can be effected only by a change of climate. 

The masked and irregular manifestations of malaria are to be treated 
in the same manner as cases of malarial fever. 



SECTION X. 
OTHER GENERAL DISEASES. 

CHAPTER I. 
RHEUMATISM. 

The rheumatic diathesis manifests itself in children by quite a dif- 
ferent group of symptoms from those seen in adults; for this reason the 
disease was formerly supposed to be a rare one in early life. It is only 
within recent years that its frequency and its peculiarities have come to 
be appreciated. For our present understanding of the subject we are 
indebted largely to the work of English physicians, especially Cheadle, 
who has brought out more fully than any one else the close connection 
existing between many conditions formerly not regarded as rheumatic. 
One who has in mind only the adult types of articular rheumatism, and 
regards arthritis as a necessary symptom for a diagnosis, will overlook 
in early life many manifestations which are clearly the result of the 
rheumatic poison. There -is seen at this period a group of clinical 
phenomena, which often occur in combination or in succession, whose 
association was not understood until they were all discovered to be related 
to rheumatism. Sometimes one member of the group and sometimes 
another is first seen, but when one has appeared others are likely soon 
to follow. 

Rheumatism in childhood, then, is manifested not alone by arthritis 
with acute or subacute symptoms, but by a large number of other condi- 
tions which are not to be regarded in the light of complications, but 
rather as forms of the disease. 

Etiology. — It is not in the province of this work to discuss the vari- 
ous theories regarding the nature of rheumatism and its exciting cause. 
The drift of medical opinion to-day is strongly toward the view that 
acute rheumatism is an infectious disease, probably of microbic origin. 
Although the character of the micro-organism is not yet determined, the 
latest observations of Poynton and Paine x point to a diplococcus. The 
excessive formation of acids in the system may be regarded as a result 
of the infection, or possibly as a condition necessary for the activity of 

1 Lancet, May 4, 1901. 

1085 



1080 OTHER GENERAL DISEASES. 

the specific poison. Under five years of age articular rheumatism is not 
common, and in infancy it is extremely rare. I once saw, however, in 
a nursing infant, a typical attack of rheumatic fever with multiple joint 
lesions. The condition is, however, so exceptional that one should be 
cautions in making the diagnosis of rheumatism in infancy. Most of the 
cases so regarded are examples of scurvy. After the fifth year both 
the articular and the other manifestations of rheumatism become very 
common, and occur with increasing frequency up to the time of puberty. 

Heredity is a very important etiological factor, and in fully two- 
thirds of the cases that have come under my care, a rheumatic family 
history was obtained. Of the other important causes, the most frequent 
are living in damp dwellings, direct exposure to cold and wet, poor 
hygienic surroundings, and insufficient food. While seen among all 
classes, rheumatism is more common among those who are badly housed. 
Attacks of rheumatism occur at all seasons, but are much more frequent 
in the spring months. One attack strongly predisposes to a second, and 
in most cases there is a history of a large number of attacks of greater 
or less severity. Among my own patients, girls have been affected with 
greater frequency than boys. 

Symptoms. — The General and Articular Manifestations. — The clini- 
cal types of rheumatism in children present very notable contrasts to 
those seen in adults. A typical attack of acute articular rheumatism such 
as is seen in adult life, with a sudden onset, high temperature, severe 
inflammation of several joints, profuse acid perspiration, and occasional 
delirium, is rarely seen in a child under eight or ten years old. In most 
of the attacks in childhood the onset is not very acute, the temperature 
is but slightly elevated — only 100° or 101.5° F. — the swelling and pain 
are moderate, and the redness is often absent. The number of joints in- 
volved is generally small, those most frequently affected being the ankles, 
the knees, the small joints of the foot, the wrists, or the elbows. These 
symptoms are often not severe enough to keep the patient in bed, and 
only the pain in the joints of the lower extremities prevents him from 
walking. The duration of these attacks is from one to three weeks, and 
in the course of a month most of them recover even without treatment. 

Not infrequently the symptoms are limited to a single joint, usually 
the hip, knee, or ankle. Possibly the joints of the upper extremity are 
affected oftener than would appear, but disease here is much more likely 
to be overlooked than when lameness is present. The swelling is mod- 
erate and may not be evident except on a close examination; in some 
cases there is none. There is stiffness of the joint, as shown by lameness, 
and there may be so much pain and soreness that the child refuses to 
walk altogether. Muscular spasm about the affected joint is often 
marked, and may be the most striking objective symptom. The tender- 
ness is sometimes localised, but it may affect the ligaments, tendons, and 



RHEUMATISM. 1087 

even the muscles. These symptoms may persist for two or three weeks 
and lead to a suspicion of incipient tuberculous disease of the joint. 
Eheumatism is distinguished by its more acute onset and usually by the 
presence of slight fever; some elevation of temperature being the rule, 
though it is not often much over 100° F. A family history of rheu- 
matism, or a history of previous similar attacks in the patient affecting 
the same or other joints, or other manifestations of rheumatism, are also 
of assistance in the diagnosis. Occasionally all doubt is removed by the 
disease extending to other joints, or by the development of endocarditis. 
In some cases the symptoms are less in the articulation than in the 
muscles, and they are dismissed as simply " growing pains/' having noth- 
ing characteristic about them except their occurrence in damp weather. 

Cardiac Manifestations. — These may occur when the articular symp- 
toms are very mild, and in some cases when they are entirely absent. 
The most frequent is endocarditis. This is much more often seen in the 
acute rheumatism of children than of adults, and probably occurs in the 
majority of all severe cases; if it does not come in the first attack, it is 
likely to be seen in the later ones. It frequently occurs with a mild 
rheumatic arthritis, often being unnoticed until valvular disease of con- 
siderable severity has developed. Sometimes there is only high fever 
with severe constitutional symptoms of an indefinite character, but no 
arthritis, and no suspicion that the attack is rheumatic until endocar- 
ditis is discovered. Such cases are not infrequent. If the patients are 
kept under observation, articular symptoms are almost certain to develop 
later, and often there are other manifestations of rheumatism, especially 
chorea. 

Pericarditis is much less frequent than endocarditis, and usually oc- 
curs in children over seven years old. It is often associated with endocar- 
ditis. The most characteristic form of inflammation in early life is a sub- 
acute, dry, fibrous form, often resulting in great thickening with extensive 
adhesions, and frequently in obliteration of the pericardial sac. When 
once started it shows a strong tendency to recurrence and persistence. 

The heart is so frequently affected in the rheumatism of childhood 
that it should be closely watched whenever articular symptoms are pres- 
ent, no matter how mild they may be ; and not only in these cases, but 
in all the conditions hereafter enumerated with which rheumatism is 
likely to be associated. 

Inflammations of other serous membranes — the pleura, peritonaeum, 
and pia mater — were much more frequently ascribed to rheumatism in 
the past than now. There is little doubt that on rare occasions any one 
of these may be due to rheumatism. The pleura is most often involved, 
but even this is rare in young children. 

Torticollis when it occurs acutely is frequently rheumatic. This 
form is characterised by its sudden development, continuous spasm, the 



1088 OTHER GENERAL DISEASES. 

greal amount of muscular soreness, the moderate pain, and the fact that 
it usually disappears spontaneously after a few days. Other manifesta- 
tions of muscular rheumatism are less characteristic and usually affect 
the muscles of the extremities. 

An a' mi a is almost invariably seen in rheumatic patients, both during 
and between the attacks. The effect of the rheumatic poison upon the 
blood resembles that of malaria. The presence of anaemia is so evident 
and its degree often so marked, that one may have great difficulty in 
distinguishing cardiac murmurs which are haemic from those due to 
endocarditis. 

Chorea. — In the article upon Chorea I have already discussed the 
association of that disease with rheumatism and expressed my own belief 
in a very close relationship existing between them. Not very infre- 
quently chorea is the first manifestation of a rheumatic diathesis, to 
be followed soon by articular symptoms or by endocarditis without such 
symptoms. In other cases chorea and acute endocarditis occur together 
without articular symptoms, or all three may be associated. Whichever 
of the thiee^ conditions is first seen, the physician should always be on 
the lookout lor the others. The frequency of rheumatism in choreic 
patients lias been variously estimated by different observers ; in my own 
cases over fifty-six per cent gave unmistakable evidence of a rheumatic 
diathesis. 

Tonsillitis.— The association of tonsillitis and pharyngitis with rheu- 
matism appears in many cases to be a close one. Children who are the 
subjects of frequent attacks should be regarded as possibly rheumatic, 
and closely watched for other signs of that disease. Acute tonsillitis 
often ushers in an attack of rheumatic arthritis, and occasionally acute 
endocarditis without articular symptoms. The nature of the relationship 
is not yet fully explained ; by many the tonsils are regarded as the struc- 
tures through which the rheumatic poison is absorbed. 

Subcutaneous Tendinous Nodules. — General attention was first drawn 
to these as a manifestation of rheumatism by Barlow and Warner, in 
1881, who described them as " oval, semi-transparent, fibrous bodies like 
boiled sago grains." They are most frequently found at the back of the 
elbow, over the malleoli, at the margin of thQ patella; occasionally on 
the extensor tendons of the hands, fingers, or toes, or over the spinous 
processes of the vertebra? or the scapulas. They are composed of fibrin, 
cells, and fibrous tissue, and vary in size from a large pin's head to a 
small bean, sometimes being as large as an almond. The nodules may 
come in crops, lasting for a few weeks and then disappearing, or they 
may last for months. An eruption of nodules is usually coincident with 
other rheumatic manifestations. These nodules are better felt than 
seen, although they may be visible if the skin is tightly drawn. They are 
certainly not common in this country; and although I have made it a 



RHEUMATISM. 1Q89 

rule to examine rheumatic patients for them, I have seen them but 
seldom, and they have been prominent in only two or (luce cases. This, 
I think, has also been the experience of most observers in New York. 
From published reports, however, they appear to be much more frequenl 
in England. There can be no doubt regarding the connection of these 
nodules with rheumatism. 

Erythema. — The connection between rheumatism and the various 
forms of erythema — marginatum, papulatum, and nodosum — has been 
very clearly shown by Cheadle. None of these are frequent conditions in 
childhood, but when seen they should always suggest rheumatism. 

Purpura. — The association of purpura with rheumatism is so 
frequent that there can be little doubt of the close connection be- 
tween the two conditions. Rheumatic purpura, however, is quite 
distinct from the other forms of purpura, and is a much less frequent 



Diagnosis. — In order to recognise rheumatism in a child, one must 
free his mind from preconceived notions of the disease drawn from its 
manifestations in adults, as very few cases correspond to the adult tvpe 
of acute rheumatism. In early life the disease is recognised not by any 
one or two special symptoms, but by the association or combination of a 
number of conditions which may appear unrelated. In determining 
whether or not any given set of symptoms is due to rheumatism, one 
should consider: (1) The family history, since in early life heredity is 
so important an etiological factor; (2) the previous history of the pa- 
tient, not only as regards articular pains and swelling, the slight joint- 
stifTness without swelling, the indefinite wandering pains in damp 
weather, and the so-called growing pains, but also the previous existence 
of chorea, frequent attacks of tonsillitis, torticollis, or erythema; (3) 
the examination of the patient, which should include a careful search 
for tendinous nodules, as well as a thorough examination of the heart 
for signs of endocarditis or pericarditis, and, in cases which are at all 
acute, the temperature. In doubtful cases with monarticular symptoms 
much importance is to be attached to the presence of slight fever, the 
abrupt onset, and tenderness of the neighbouring muscles and tendons — 
all occurring without a history of traumatism. Rheumatism is more 
often overlooked than confounded with other diseases ; although in child- 
hood multiple neuritis and tuberculous and syphilitic bone disease are 
often mistaken for it, and in infancy the same is true of scurvy. The 
extreme infrequency of rheumatism during the first two years of life 
should always make one sceptical regarding it. In an infant, when the 
symptoms are confined to the legs and are not accompanied by fever, they 
are almost certain to be due to scurvy, even though the gums are normal 
and ecchymoses have not yet appeared. Multiple gonococcus arthritis has 
often been diagnosticated rheumatism. 
70 



1090 OTHER GENERAL DISEASES. 

Prognosis. — Rheumatism in a child is in itself seldom if ever danger- 
ous to life. In the groat majority of cases the articular s}Tnptoms soon 
disappear, even without special treatment. The danger from the disease 
consists in its cardiac complications. One attack of rheumatism is almost 
certain to be followed by others, and when once the heart has been 
affected its lesions are likely to increase with each recurrence of the 
disease. 

Treatment. — Rheumatism in children derives its chief importance 
from its relation to cardiac disease. Cardiac complications are so fre- 
quent and so serious that everything possible should be done to avert 
rheumatism from those who by inheritance are especially predisposed to 
it, to prevent its recurrence in a child who has once had the disease, and 
during an attack to prevent the heart from becoming involved. The 
relation of diet to rheumatism is very imperfectly understood. The best 
opinion at the present time is that there is no very close connection 
between the two. The underclothing should be of flannel during the 
entire year, in summer the lightest weight being worn. The feet should 
be carefully protected, and exposure in damp weather avoided. Indoor 
occupations should be chosen for rheumatic boys. 

The tendency to recurrence is so strong in this disease that a child of 
rheumatic antecedents, who has shown in the various ways mentioned a 
marked predisposition to rheumatism, and who has had an attack, even 
though a mild one, should, if possible, spend the winter and spring in 
some warm, dry climate, or even remain there permanently. Otherwise 
in most such children, it is only a question of time when, with the re- 
peated attacks, the heart will become involved. 

To avert the danger of cardiac complications during an attack of 
rheumatism, or to limit their extent, there are two things which should 
invariably be insisted on : First, to confine to the house and in a warm 
room every child with rheumatic pains, no matter how mild; secondly, 
if fever is also present, to keep the child in bed while it continues, even 
though it may never be above 100° F. Absolute rest and the equable 
temperature thus secured are unquestionably of more importance than 
anything else in protecting the heart during a rheumatic attack. With 
these precautions must be combined an early diagnosis. In very many, 
perhaps in most cases, the harm is done before the true nature of the 
disease is suspected, the symptoms being dismissed as of slight impor- 
tance because the articular manifestations are not very severe. Children 
who have once had rheumatism should be closely watched during chorea 
and other diseases related to rheumatism, the heart should be frequently 
examined, and the physician should be on the alert for the first articular 
symptoms. 

Aside from the measures just mentioned, the treatment of rheuma- 
tism in childhood is to be conducted very much like that of adult life. 



DIABETES MELLITUS. 109] 

In the most acute attacks either salicylate of soda (gr. v every t hree hours 

to a child of five years), oil of wintergreen, aspirin, or salicin should 
be given; as the majority of cases are not very acute, marked improve- 
ment is by no means always obtained by these dvu^. Alkalies should be 
given in all cases in combination with the specific remedies, hut par- 
ticularly in those in which there is hyperacidity of the urine. Either the 
acetate or citrate of potassium or the bicarbonate of sodium may be used, 
a sufficient quantity being administered to render the urine alkaline. 

Quite as important as these drugs is the use of general tonics, partic- 
ularly iron and cod-liver oil. These should be given not only between 
attacks to fortify patients against their recurrence, but also in subacute 
cases which are sometimes influenced very little or not at all either by 
salicylates or alkalies. 

CHAPTER II. 
DIABETES MELLITUS. 

In this chapter will be attempted only a description of the peculiar 
features which diabetes presents when affecting young patients. It is 
a very infrequent disease in children. Of 1,360 cases of diabetes col- 
lected by Pavy, only eight were under ten years of age. In a series 
of 700 cases collected by Prout, only one case was under ten years. In 
a series of 380 cases collected by Meyer, only one case was under ten 
years of age. 

Etiology. — Stern, in a series of 117 collected cases of diabetes in chil- 
dren, states that 47 were females and 31 males, the sex in the other 
cases not being given. Although extremely rare, cases have been ob- 
served during the first two years, and even during the first year of life. 
Statistics on this point are not altogether trustworthy, since some cases 
of temporary glycosuria have certainly been included. 

Among the etiological factors, heredity is one of the most important. 
Pavy reports the case of a child dying of diabetes at two years in whose 
family the disease had existed for three generations. Instances have 
been recorded of the occurrence of diabetes in four or five children of 
the same family. Inherited gout, insanity, and nervous diseases gen- 
erally, may be looked upon as factors in the production of diabetes. Sev- 
eral of the cases reported in children have been preceded by injuries 
received upon the head. In a number of my own cases the disease has 
followed the consumption of large quantities of sugar for a long time. 
Often no adequate cause can be found. 

Symptoms.— The most important early symptoms are thirst, polyuria, 
and wasting; their development is often quite rapid. The thirsl is 
intense, often leading children to drink four or five pints of fluid a day. 



1092 OTHER GENERAL DISEASES. 

The amount of urine passed varies from one to eight quarts daily. The 
specific gravity is from 1.026 to 1.040, and the usual amount of sugar 
is from three to five per cent, rarely more. Albumin is not infrequently 
present. Incontinence of urine is an important symptom, and often one 
of the earliest to be noticed. The wasting is usually quite rapid, so that 
a child may lose as much as six or eight pounds in a month. It is gen- 
erally accompanied by anaemia. The appetite may be poor; at times, 
however, it is voracious. Other symptoms of less importance are a dry 
mouth, scanty perspiration, irregular sleep, occasional epistaxis, furuncles 
and abscesses, decayed teeth, and genital irritation. 

The course of the disease is much more rapid in children than in 
adults, and, as a rule, the younger the child the more rapid its progress. 
The majority of the cases prove fatal in from two to four months from the 
time the symptoms are sufficiently marked to make the diagnosis possible. 
Yery few last more than six months; occasionally, however, one of the 
milder type may be prolonged from one to two years. 

The progress of the disease is marked by continuous wasting, which 
may result in a marked degree of marasmus, and prove fatal. Some are 
carried off by intercurrent pneumonia or tuberculosis, but the majority 
die comatose. When coma develops, the case may be considered hopeless, 
and death is likely to be postponed but a few days. The cause of diabetic 
coma has not yet been satisfactorily explained, but it is usually believed 
to be due to the presence of the acetone bodies in the blood. 

Diagnosis. — Diabetes is apt to be overlooked, because of the common 
neglect of urinary examinations in children. The prominent symptoms 
— thirst, polyuria, and wasting — when associated, should always attract 
attention. Incontinence of urine, accompanied by marked wasting, is 
always suspicious. In some cases genital irritation may be the most 
prominent early symptom. A positive diagnosis is made only by an 
examination of the urine. 

Prognosis. — In few diseases is the prognosis so bad as in diabetes in 
children. So high an authority as Senator declares that diabetes in 
children is hopeless and all treatment is useless. From a study of sev- 
enty-seven cases, Stern reaches the same conclusion. There are, how- 
ever, cases on record in which recovery is believed to have taken place. 
The cases which I have seen have all terminated unfavourably. In a 
given case the prognosis, as to the duration of the disease, is rendered 
much worse by the presence in the urine of large amounts of diacetic 
and j8-oxybutyric acids. This condition is even more serious than is a 
high percentage of sugar ; that the patient will then live more than three 
months is highly improbable. 

Treatment. — The indications for treatment are the same in children 
as in adults: first, diet; secondly, general hygienic measures. From 
the use of drugs nothing can be expected. 



INDEX. 



Abdomen, examination of, 38; growth of, 
24; in rickets, 255. 

Abscess, alveolar, 267; cerebral, 731; 
symptoms, 732; treatment, 734; cere- 
bral, in acute otitis, 899; ischio-rectal, 
431 ; mammary, 114 ; hepatic, 437 ; peri- 
toneal, 443 ; peritonsillar, 300 ; psoas, in 
spinal caries, 858 ; retro-oesophageal, 
306; retro-pharyngeal, in Pott's disease, 
287, 855; retro-pharyngeal, of infancy, 
305; subphrenic, 453. 

Abscess, multiple, in newly born, 84. 

Acetonuria, 604. 

Achondroplasia (see Chondro-dystro- 
phy), 760. 

Acid, hydrochloric, increased by lavage, 
334; hydrochloric, in gastro-enteric in- 
toxication, 359; hydrochloric, in stom- 
ach digestion, 309 ; in chronic gastric 
indigestion, 334. 

Adenitis, acute, 836; acute axillary, 
836; acute cervical, 836; acute in- 
guinal, 836 ; cervical, in diphtheria, 
976; in influenza, 1073; in measles, 
938; retro-oesophageal, 306; retro- 
pharyngeal, 284; simple acute, 836; 
simple chronic, 839 ; syphilitic, 840 ; 
tuberculous, 840; treatment, 846. 

Adenoid vegetations of pharynx, 288, 457; 
symptoms, 290 ; treatment, 292 ; asthma 
from, 485; causing chronic nasal ca- 
tarrh, 457; chronic laryngitis with, 469; 
in rickets, 256; with adenitis, 839. 

Adenoma of umbilicus, 111. 

Agenesis, cortical, 747. 

Airing, when allowed out of doors, 8. 

Air-space required by infants, 10. 

Alalia, 686. 

Albumin water, preparation of, 160. 

Albuminuria, orthostatic or cyclic, 600 ; in 
chronic cardiac disease, 585; in chronic 
nephritis, 619; in measles, 938; in scar- 
let fever, 917. 

Alcohol, as stimulant, 51; as tonic, 52; 
effect on breast milk, 172; use of, in 
diet of nurse, 136. 

Amaurotic family idiocy, 759. 

Amyloid degeneration, in chronic bone 
disease, 854; of the intestines, 389; of 
the liver, 389; of the spleen, 389. 



Anaemia, cardiac murmurs in, 593; fol- 
lowing diphtheria, 982; pernicious, 818; 
pseudo-leukaemie, of infancy, 8KJ; treat- 
ment, 820; simple, 813; treatment, 820; 
in rickets, 256 ; in scurvy, 238 ; in tu- 
berculosis, 1043 ; preceding tuberculo- 
sis, 1031. 

Anaesthesia, partial, in multiple neuritis, 
803. 

Anaesthetics, those best for children, 66. 

Anasarca, general, in acute diffuse ne- 
phritis, 614; in chronic cardiac disease, 
585. 

Aneurism, 595. 

Antipyretic drugs, 51. 

Antipyretics, 49; in acute broncho-pneu- 
monia, 518. 

Antipyrine, in chorea, 674; in catarrhal 
croup, 464; in pertussis, 964; scaiia- 
tiniform rash from, 922. 

Antitoxine, in the treatment of tetanus, 
91; eliminated by human milk, 137. 

Anuria, 604. 

Anus, fissure of the, 428; imperforate, 
115. 

Aorta, abnormal origin of, 571; aneurism 
of, 595; atheroma of, 595; congenital 
narrowing of, in chlorosis, 815 : hypo- 
plasia of, 595; thrombosis of, 595. 

Aortic insufficiency, 587; stenosis, 588. 

Aphasia, functional, 686; in acquired 
cerebral paralysis, 754; after typhoid 
fever, 1014; motor, in cerebral tumour, 
737, 738. 

Aphonia, hysterical, 682. 

Appendicitis, 415; lesions, 416; symp- 
toms, 416 ; diagnosis, 418 ; leucocyte 
count an aid in, 419; treatment, 419. 

Arm, paralysis of, at birth, 108. 

Arsenic, as a tonic, 52; dosage in chorea, 
674. 

Arteries, hypogastric, in foetal circula- 
tion, 564; hypoplasia of. 594; umbilical, 
in foetal circulation, 564. 

Arthritis, acute, of infants. 850; acute 
suppurative, syphilitic. 867; gonococ- 
cus, 634, 639. 851; rheumatic, 1086, 

Arthrogryposis (see TETANY), 856. 

Artificial feeding, 178 ; versus wet-nurs- 
ing, 165. 

1093 



1094 



INDEX. 



Asians lumbrlcoides (see Wobms, INTES- 
TINAL), 422. 

Ascites, 4.".l > : chylous, 4:>2: in acute dif- 
fuse Dephritis, (ill; in cirrhosis of 
liver. 439; with chronic peritonitis, 44.">; 
With tuberculosis of the peritonaeum, 
447. 

Asphyxia, death from, in young children, 
47: from overlying, 40; from aspiration 
of food. 40: from enlarged thymus, 40: 
in convulsions, 654; in retro-pharyngeal 
abscess. 280: in the newly born. 09; 
from tuberculous bronchial lymph 
nodes. 1045; methods of resuscitation, 
72: sudden, in retro-cesophageal ab- 
scess. 307. 

Aspiration of chest in empyema. 560. 

Asthma, 483: etiology, 485; symptoms, 
4S5; diagnosis, 487; prognosis. 487; 
treatment, 488 ; catarrhal, 486 : with 
adenoids. 291: simulated by tuberculous 
bronchial glands, 1045. 

Ataxia, Friedreich's, 794 : in multiple 
neuritis, 803. 

Atelectasis, acquired, 545; from compres- 
sion, 545; from obstruction, 545: in 
delicate infants, 546; causing sudden 
death, 40 ; congenital, 73. 

Atheroma, 595. 

Athetoid movements, 075; in acquired 
cerebral paralysis, 754 ; in birth paral- 
ysis, 751. 

Athetosis, 075. 

Atresia ani, 341. 

Atrophy, infantile (see Marasmus), 227; 
muscular, facial type, 799; in multiple 
neuritis, 803 : juvenile form, 799 ; pro- 
gressive muscular, hand type, 796 ; 
peroneal type, 797. 

Babcock's centrifugal machine, 145. 

Bacillus of diphtheria, 969, 990; dis- 
tribution in the body, 972; in milk, 
140 ; in healthy throats, 991 ; in laryn- 
geal diphtheria, 991 ; non-virulent, 
991; of dysentery (Shiga) in ileo- 
colitis, acute, 306; in gastro-intestinal 
intoxication, acute, 349; of Eberth, in 
typhoid fever, 1009: Klebs-Loeffler (see 
B. Diphtheria), 909; lactis aerogenes, 
311 ; of Pfeiffer, in influenza, 1070 ; 
pseudo-diphtheria, 295; of tuberculosis. 
1017; in acute broncho-pneumonia, 491. 

Backwardness, 760. 

Bacteria, etiology of diarrhoea. 349; in 
human milk, 137 ; in cow's milk, 139, 
144, 151, 153; means of reducing the 
number in cow's milk, 143 : intestinal, 
311. 

Bacterium coli communis, 311; in appen- 
dicitis, 416; in peritonitis, 443. 

Bacterium lactis aerogenes, 311. 

Balanitis, 034. 

Band, abdominal, 1, 3. 

Barley water, directions for making, 100; 
use during first year, 200. 



Barlow's disease (see SCORBUTUS), 233. 

Bath, at birth, 1, 2 ; cold, 50 : in acute 
broncho-pneumonia, 518 : in asphyxia of 
newly born, 71; evaporation, 50; hot, 
56; hot air, 56; vapour, 50; mustard, 
57; bran, 57; tepid, 57; shower, 57; 
cold sponge, 57; hot, in asphyxia, of 
newly born, 71 ; in typhoid fever, 1017. 

Bed-wetting, 641. 

Beef broth, 160; extracts, 159; juice, 
159; preparations of, 159; raw scraped, 
160. 

Belladonna. .">4 : elimination of, in milk, 
137: scarlatiniform rash, 907. 

Bile, physiological action of, 310. 

Bile-ducts, congenital malformations of, 
77. 

Birth paralyses, 104; cerebral, 104; 
spinal, 104; peripheral, 104. 

Bladder, control acquired, 041; exstrophy 
of, 033; haemorrhage from, in newly 
born, 102; stone in, 646; training to 
control, 4. 

Bleeders, 823. 

Blindness, hysterical, 681; stigma of de- 
generation, 771; transient, in pertussis, 
960. 

Blood, circulation of, in early life, 504; 
corpuscles, red, 809, corpuscles, white, 
809 ; diseases of, 809 ; haemoglobin, 
978 ; in empyema, 557, 811 : in leukae- 
mia, 820 ; in measleSt 939 ; in pernicious 
anaemia, 818 : in pneumonia, 811 ; in 
pseudo-leuksemic anaemia, 817 : in scar- 
latina, 919 ; in simple anaemia, 814 : 
leucocytes of, varieties of, 810 ; leu- 
cocytosis, 811 : Plasmodium malariae in, 
1075, 1082 ; specific gravity, 809. 

Blood-vessels, diseases of, 595 : aneurism, 
595 ; arterial hypoplasia, 595 ; athero- 
ma, 595 ; embolism, 595 ; thrombosis, 
595. 

Boil (see Fcrunculosis), 887. 

Bone-marrow in leukaemia, 821. 

Bones, diseases of, 850; in hereditary 
syphilis, 1054; in late syphilis, 1063; 
lesions of, in rickets, 243; microscopical 
changes of, in rickets, 240; syphilitic 
diseases of, 867; tuberculous diseases 
of, 852; etiology, 852; lesions, 853. 

Bothriocephalus latus, 420. 

Bottles, nursing, choice and care of, 198. 

Bowels, haemorrhages from (see Hemor- 
rhage. Ixtestixal) ; movements of, ir- 
regularity in times for, 403 ; training 
to control movements, 4. 

Bow-legs in rickets, 254. 

Bradycardia, 594. 

Brain, diseases of, 694 : abscess of, 731 ; 
atrophy and sclerosis of, 749 ; atrophy 
and sclerosis of, in acquired cerebral 
paralysis, 752; cysts of, in infantile 
cerebral paralysis, 749; malformations 
of, 694; tuberculosis of, 1029; tumour 
of, 731; weight of, 647. 
Bran bath, 57. 



INDEX. 



1095 



Breast, abscess of, in newly horn, 113. 

Breast-feeding, 166; schedule for, 168. 

Breast milk (see Milk, Woman's). 

Breath, offensive, in ulcerative stomatitis, 
273. 

Breathing, noisy, with adenoids, 200; 
stridulous, in diseases of the larynx, 
463, 46G, 469; in retro-oesophageal ab- 
scess, 306. 

Breck's feeder, 13. 

Bright's disease (see Nephritis), 611. 

Bromides, elimination of, in milk, 137. 

Bronchi, catarrhal spasm of, 486; diph- 
theria of, 975; foreign bodies in, 471; 
lesions of, in acute broncho-pneumonia, 
494; lymph nodes of, in tuberculosis, 
1021, 1027 ; tube casts of, 482. 

Bronchial glands (see also Lymph Nodes, 
Bronchial), enlarged, cause of asthma, 
485; in acute broncho-pneumonia, 500; 
reflex cough from, 484. 

Bronchitis, acute catarrhal, 475; symp- 
toms, 476; diagnosis, 478; treatment, 
479 ; prophylaxis, 480 ; asthma follow- 
ing, 485 ; capillary (see Broncho- 
pneumonia, Acute)," 492, 502; attacks 
of asthma resembling, 486 : chronic, 
482; etiology, 482; symptoms, 483; 
diagnosis, 483; treatment, 483; chronic, 
bronchiectasis in, 483; chronic, in 
rickets, 248; diphtheritic, broncho-pneu- 
monia in, 512; fibrinous, 481; treat- 
ment, 482; in pertussis, 959; in typhoid 
fever, 1013; spasmodic (see Asthma), 
•486; tuberculous, 1036. 

Bronchiectasis in chronic bronchitis, 483; 
in broncho-pneumonia, chronic, 540. 

Broncho-pneumonia, acute, 492; bacteri- 
ology, 493; complications, 513; com- 
plicating influenza, 512 ; diphtheria, 
978; measles, 512; pertussis, 959; rick- 
ets, 248; diagnosis, 514; etiology, 493; 
lesions, 494; associated, in the lung, 
500; physical signs, illustrated, 508; 
protracted or persistent form, 510; sec- 
ondary pneumonia with measles, 512; 
ileo-colitis, 513; influenza, 512; per- 
. tussis, 511; diphtheria, 512; prognosis, 
515; protracted cases, 510; symptoms, 
501; temperature charts of, 505; ter- 
minations, 499; treatment, 517; prophy- 
laxis, 517. 

Broncho-pneumonia, chronic, 540; lesions, 
540; symptoms, 541; physical signs, 
541 ; treatment, 542. 

Broncho - pneumonia, tuberculous, 1035, 
1036 ; rapid cases, 1089 ; protracted 
cases, 1089 (see also Tuberculous 
Pneumonia). 

Broths, directions for making, 160. 

Buhl's disease, 91. 

Buttermilk, 156, 206, 382. 

Calamine lotion, 885. 

Calculi, biliary, 441; renal, 627; pyelitis 
with, 628; vesical, 646. 



Calories, required daily by healthy In- 
fants, us; method of calculating, 
value of differenl food stuffs in, 127, 

IT!). 

Cancrum oris (sec Stomatitis, i 

QBENOU8), L'70. 

Carbohydrates, function of, in diet, 126, 
Carcinoma of brain, 784; of kidney, <vs2; 

of stomach, 338. 
Carrel's apparatus for Inflating the 

lungs, 72. 

Casein, 147, 181. 

Caseinogen, 1 IT. 

Casts in urine of chronic nephritis, 618. 

Catarrh, Eustachian, in hypertrophy of 
tonsils, 302; gastric, :\:\\ ; nasal acute, 
454; prophylaxis, 466; chronic, 4.",7 : 
with adenoid growths, 200; foreign 
bodies in nose, 457; nasal polypi, 468; 
rhinitis, simple chronic, 458; syphilitic, 
459; rhino-pharyngeal, with adenoids, 
290. 

Catheters, sizes required for infants. 508. 

Cellulitis of abdominal wall with perito- 
nitis, 443; of neck, in scarlet fever, 
916. 

Cephalhematoma, external, 95; internal, 
96. 

Cereals, 160; allowed from third to sixth 
year, 213. 

Cerebellum, abscess of. 731; tumours, 734. 

Cerebral paralysis, 747 : from hemor- 
rhage, 104; etiology, 104: lesions. 108; 
symptoms, 105 ; prognosis, 106 ; treat- 
ment, 106. 

Cerebro-spinal meningitis (see Menin- 
gitis, Acute Cerebro-spinal), 701. 

Cerebrum, abscess of, 731; tumour, 7.*{4. 

Chest, circumference of, 20; development 
of, 23; "funnel" chest, 24; in rickets, 
251 ; lateral depressions of, in adenoids, 
290. 

Cheyne-Stokes respiration in cerebro- 
spinal meningitis, 7(H); in tuberculous 
meningitis; 724. 

Chicken-pox (see Varicella), 046. 

Chloral, dosage and administration. ."»:;. 

Chlorosis, 815; etiology. 815; lesions, 
815; symptoms, 81."); prognosis. 816; 
diagnosis, 816; treatment. 820. 

Cholera infantum, 361; symptoms, 362; 
treatment, 364. 

Chondrodystrophy, 762. 

Chorea, 669; acute endocarditis in. 584; 
diagnosis, 584; endocarditis in, 672; 
etiology, 669; following birth paralysis, 
751; typhoid fever. 1014; heart mur- 
murs in, 672; prognosis of. 673; hys- 
terical, 682; with adenoids, 201: in 
rheumatism, 670. 1088; pathology, 671; 
post-hemiplegic, 676; in cerebral palsy. 
751: prognosis. 673; relation to rheuma- 
tism, 670; speech in. 672, 686; symp- 
toms, 671; treatment, 07.*?. 

Circulation, changes in. at birth, 566; 
foetal, 565; in early life, 566. 



1096 



INDEX. 



Circulatory system, diseases of the, 565. 

Citrate of soda. 208. 

Claw-hand, Tin;. 

Cleft palate. 262. 

ClQthing at birth, 2; in summer, 3; at 
night. 3; in summer diarrhoea, 356. 

Club-foot with spina bifida, 775. 

Codeine, dosage of, 53. 

Cod-liver oil as tonic, 52. 

Cold, as an antipyretic, 49; ice cap, 49; 
sponging. 49 ; pack, 50 ; bath, 50 ; irri- 
gation of the colon, 50; in the head, 
with adenoids, 290; therapeutics of, 56. 

Cold sores, 263. 

Colic, habitual, 197; intestinal, 400; renal, 
627. 

Colitis, acute (see Ileo-colitis, Acute), 
365; amoebic, 389; membranous, 372; 
membranous gastritis with, 329. 

Collapse, in acute broncho-pneumonia, 
treatment of, 519; in acute peritonitis, 
467 ; in ulcer of stomach, 337. 

Collapse, pulmonary (see Atelectasis, 
Acquired), 545. 

Colles's law, 1054. 

Colon, abnormal position of, 342; con 
genital atresia of, 114 ; dilatation of, 
407; in rickets, 255; follicular ulcers of 
370; hypertrophy of, 407; irrigation of. 
50, 65; in gastro-enteric intoxication 
359; in acute ileo-colitis, 382; in intes 
tinal indigestion, 388; membranous in 
flammation of, 373. 

Colostrum, 128; corpuscles of, 128; com- 
position of, 128. 

Coma, in diabetes mellitus, 1091. 

Compression-myelitis (see Myelitis), 
780. 

Condensed milk, cause of rickets, 241; 
composition of, 155; dilution of, for in- 
fants, 155; fresh, 155. 

Congenital, ichthyosis, 875; myotonia, 
677; rickets, 257; syphilis, 1057; tuber- 
culosis, 1019. 

Conjunctiva, catarrhal inflammation of, 
in measles, 932 ; haemorrhage from, in 
newly born, 102. 

Constipation, in rickets, 255; chronic, 401; 
treatment of, 403 ; dilatation of colon 
in, 407; anal fissure from, 428; early 
symptom of rickets, 248 ; from defi- 
cient fat in food, 196 ; in intussuscep- 
tion, 413. 

Contractures, hysterical, 681. 

Convulsions, 649; symptoms, 651; diag- 
nosis, 652; prognosis, 654; treatment, 
654; causing death without other symp- 
toms, 47; chloral in, 655; epileptic, 664; 
hysterical, 682; in acquired cerebral 
paralysis, 753; in cerebral haemor- 
rhages, 105; in congenital atelectasis, 
75; in pertussis, 960; in rickets, 256; 
morphine in, 655; in status lymphat 
icus, 832. 

Cord, spinal, diseases of, 772; malforma- 
tions of, 772; meningitis, 778; myelitis, 



778; pressure-paralysis of, 780; tumours 
of, 793; weight of, 647. 

Cord, umbilical, care of, 1; separation 
of, 2. 

Cornea, ulcers of, in chronic ileo-colitis, 
387. 

Corpuscles of blood, 809. 

Coryza, 454; early symptoms of measles, 
931; syphilitic, 459, 1059. 

Cough, hysterical, 682; reflex, 483; from 
pharyngeal irritation, 484; elongated 
uvula, 484; from pharyngeal mucus, 
484; from aural irritation, 484; from 
cardiac disease, 484; of puberty, 484; 
periodical, at night, 484; from Pott's 
disease, 484 ; spasmodic, in retro-oesoph- 
ageal abscess, 307; in tuberculous 
bronchial glands, 1045; whooping (see 
Pertussis), 954. 

Counter-irritants, 54. 

Cow's milk (see Milk), 138. 

Cranio-tabes, early symptom in rickets, 
249. 

Cranium, syphilitic nodes on, 870. 

Cream, 147; to secure different percent- 
ages of, 148, 149. 

Cream-gauge, 132, 145. 

Credo's method of preventing ophthalmia 
neonatorum, 1; treatment of ophthal- 
mia, 88. 

Cretinism, sporadic, 765. 

Croup, bronchial, 481; catarrhal, 462; 
kettle, 60; spasmodic, 462. 

Croupous tonsillitis, 295. 

Cry, causes and varieties of, 34; in dis- 
eases, 34; in colic, 401. 

Cryptorchidism, 633. 

Cups, dry, indications for, 55. 

Cyanosis, in acute broncho-pneumonia, 
501, 503 ; in acute inanition, 218 ; in 
chronic cardiac disease, 585; in congen- 
ital atelectasis, 75; in congenital dis- 
ease of heart, 571; in diphtheritic pa- 
ralysis, 806; in malaria, 1079, 1081; 
of face, from pressure at root of lung, 
1045. 

Cyclic vomiting, 321. 

Cyst, of brain, 734; of brain in infantile 
cerebral paralysis, 749. 

Cysticerci, 420. 



Dactylitis, syphilitic, 873; tuberculous, 
865. 

Deaf-mutism, 771; stigma of degenera- 
tion, 771. 

Deafness following mumps, 968 ; with 
adenoids, 290; with hypertrophy of ton- 
sils, 302; sudden, in late syphilis, 1064. 

Death, most frequent causes of, at differ- 
ent ages, 43; sudden, causes of, 44. 

Deformities, hysterical, 681; in rickets, 
250. 

Degeneration, stigmata of, 770. 

Deltoid, paralysis of, at birth, 108. 

Dental caries, 266. 



INDEX. 



1097 



Dentition, 27; eruption of first teeth, 28; 
eruption of permanent teeth, 29; de- 
layed, 28; before birth, 28; difficult, 
268; in rickets, 25.-). 

Dermatitis, exfoliative, of newly born, 
875; gangrenous, 88G. 

Development, conditions interfering with, 
30; muscular, 25; of body, 15. 

Dew's method of inducing artificial res- 
piration, 71. 

Dextrocardia, 571. 

Diabetes insipidus, 605. 

Diabetes mellitus, 1091. 

Diacetonuria, 604. 

Diagnosis, general considerations in, 31. 

Diapers, 3. 

Diaphragm, hernia through, 115. 

Diarrhoea, general consideration of, 343; 
deaths from in New York in five years, 
343; prevalence during summer, 345; 
impure milk as a cause, 344; observa- 
tions of The Rockefeller Institute on 
association of feeding impure milk and 
diarrhoeal disease ; 345 et seq. ; inflam- 
matory (see Ileo-colitis, Acute). 
365 ; in chronic intestinal indigestion, 
394 ; in intestinal tuberculosis, 392 ; 
summer, 348. 

Diet (see also Feeding), as cause of 
chronic constipation, 402; cause of 
rickets, 241; in acute gastro-enteric in- 
fection, 357; in acute gastric indiges- 
tion, 327; in chronic constipation, 404; 
in chronic gastric indigestion, 334; in 
dental caries, 267 ; in eczema, 883 ; in 
intestinal indigestion, 398 ; in malnutri- 
tion, 225; in rickets, 259; in scurvy, 
241; of nurse, effect on milk, 136. 

Dietary of the infant, 127. 

Digestion, gastric, 308 ; duration of, 310 ; 
in infancy, 309; intestinal, 310. 

Digestive system, diseases of the, 262. 

Digitalis, dosage, 52; in cardiac disease, 
580, 591. 

Dilatation of the stomach, 335. 

Diphtheria, 969 : bacillus (see Bacillus 
of Diphtheria), 969; broncho-pneu- 
monia in, 512, 978, 986; blood in, 
978; cardiac failure in, 988; cardiac 
thrombi in, 977 ; catarrhal, 973, 979 ; 
complications and sequelae, 986; diag- 
nosis, 988; bacteriological, 990; clinical, 
988; from pseudo-diphtheria, 991; dis- 
infection after, 995; distribution and 
mode of communication, 970; etiology, 
969; fibrinous bronchitis in, 481; im- 
munization, 994; ileocolitis in. 987; in- 
cubation, 971 ; lesions, 972 ; membrane, 
973; membranous gastritis in, 329; 
proctitis in, 429; myocarditis in, 591. 
988; nasal syringing in, 996; nephritis 
in, 977, 985; of oesophagus, 304; otitis 
in, 986 ; paralysis after, 987 ; paralysis 
in, 804 ; prognosis, 992 ; prophylaxis, 
993; quarantine, 993; simulated after 
tonsillotomy, 304; symptoms, 978; 



thrombosis in, 986; loxins of. 
treatment, 905; local, 996; serum, :t'.iT; 
of children exposed, 994; of inspected 
cases, 994; laryngeal, 979, 988, L008; 
nasal, 981, 985; pseud., (see Psbudo- 

DlPHTHBEIA), 295; sea rla I in:. I. 904 J 

Bcarlatlnlform erythema In, 922; ton- 
sillar, 080. 

Diphtheria am iloxine, dosage of, 
Immunizing dose of, ( .t ( .M: Influence on 
mortality of cities, 1001 ; local and 
general effects of, 999; other treat- 
ment with, 9!)5, !)!)<;; real and alleged 
dangers from, 1000; strength of, 997; 
time of administration, 998. 

Diplegia, in birth paralysis, 750; in 
meningeal haemorrhage, 10<; ; spastic, 
747. 

Disease, peculiarities of, in children, 29; 
etiology, 29; symptomatology and diag- 
nosis, 30 ; pathology, 40; prognosis, 42; 
prophylaxis, 47; therapeutics. 48. 

Diverticulum, Meckel's, 111. 

Dover's powder, dosage of, 53. 

Dropsy (see also CEdema) ; in acute dif- 
fuse nephritis, 611, 612; in chronic car- 
diac disease, 580; in chronic nephritis, 
619; in tuberculosis, 1040; without 
renal disease, 231. 

Drugs, administration of, 48; antipyret- 
ics, 49; elimination of, in breast milk, 
137 ; well borne, 54 ; not well borne, 
54. 

Duct, amphalo-mesenteric, 111. 115. 

Ductus arteriosus, closure of, 564; in 
foetal circulation, 564; patent, 570; 
venosus, closure of, 565; in foetal cir- 
culation, 564. 

Duodenum, congenital atresia of, 114. 

Dura mater, haematoma of, 698; throm- 
bosis of the sinuses of, 729. 

Dysentery (see Ileo-colitis, Acute), :{*i5. 

Dysphagia, hysterical, 682; in retro- 
pharyngeal abscess, is:*. 

Dyspnoea, evidence of, 36; from tubercu- 
lous bronchial lymph nodes, 1047; in 
acute catarrhal laryngitis, 467; in ca- 
tarrhal spasm of larynx. 463; in chronic 
cardiac disease. 585; Inspiratory, in 
retro-cesophagcal abscess. :*»<>7 : from 
pressure of abscess on pneumogastric, 
307 ; spasmodic, in asthma, 486. 



Ear, anomalies of, as stigmata of defen- 
eration, 771; middle, Inflammation of 
(see Otitisi. 894; in measles, 938; in 
scarlet fever, 916. 

Ecchymoses in purpura. 825; in scurvy, 
238; in leukaemia, 822. 

Echinococcus of liver. 411. 

Eclampsia (sec Convulsions), 649. 

Ecthyma gangrenosa, 888. 

Ectocardia, 571. 

Eczema. 879; etiology, 879; diagnosis, 
8S2 ; treatment, 883; intertrigo, B 



109S 



INDEX. 



Emboli, Infectious, in malignant endo- 
carditis. 682. 

Embolism, 686; in diphtheria. 986. 

Emphysema. 547; symptoms. 548: acute, 
in bronchitis of infants, 470; in acute 
broncho-pneumonia, 500 ; in pertussis, 
059. 

Empyema, 554; lesions, 554; symptoms, 
556; diagnosis, 557: treatment, 560; in 
acute broncho-pneumonia, 500. 

Encephalocele, 604 ; symptoms, 696 ; 
treatment, 696. 

Endarteritis, syphilitic, of brain, 1056; 
tuberculous, 721. 

Endocarditis, acute simple, 582; lesions, 
583 ; symptoms, 583 ; treatment, 589 ; 
in chorea, 582 ; chronic (see also 
Heart, Valvular Disease), 584; foe- 
tal, 568 ; in chorea, 672 ; in rheuma- 
tism, 1088 ; malignant, 591. 

Enemata, 65; nutrient, 65; drugs by, 65; 
astringent, in chronic ileo-colitis, 388; 
in chronic constipation, 406; in colic, 
401; injuries to rectum from, 429. 

Enuresis, 641; etiology, 641; symptoms, 
642; treatment, 643; stigma of degen- 
eration, 771. 

Ependymitis, acute, in hydrocephalus, 
743. 

Epidermis, exfoliation of, in congenital 
ichthyosis, 876; exfoliation of, in newly 
born, 875. 

Epilepsy, 663 ; diagnosis, 667 ; hysterical, 
682; in acquired cerebral paralysis, 754; 
in birth paralysis, 751; insanity fol- 
lowing, 757 ; intestinal putrefaction in, 
663; Jacksonian, in cerebral tumour, 
737; mental condition in, 666; pathol- 
ogy, 664; prognosis, 667; status epi- 
lepticus, 667; stigma of degeneration, 
771; symptoms, 664; treatment, 668. 

Epiphyseal separation in acute arthri- 
tis, 851; in scurvy, 238; in syphilis, 
867. 

Epiphyses, enlargement of, in rickets, 
253; in syphilis, 868. 

Epiphysitis, acute (see Arthritis, 
Acute), 850; syphilitic, 867, 1055. 

Epispadias, 632. 

Epistaxis, 460; in anaemia, 814; in per- 
tussis, 958; in purpura, 827; in scurvy, 
238. 

Epitrochlear lymph nodes in syphilis, 
1065. 

Erb's paralysis, 109. 

Erysipelas in newly born, 85. 

Erythema, following diphtheria antitox- 
ine, 1000 : in influenza, 1073 : intertrigo, 
882; in intestinal indigestion, 397; in 
rheumatism, 1089; of the buttocks in 
marasmus, 231; scarlatiniform, causes, 
922. 

Estlander's operation, 563. 

Eustachian tube in acute otitis, 895; ob- 
struction of, in hypertrophy of tonsils, 
302. 



Examination of sick child, 33. 

Exercise, importance of, 7; caution re- 
garding, in heart disease, 590; in anae- 
mia, 820. 

Exstrophy of bladder, 633. 

Eye, anomalies of, as stigmata of degen- 
eration, 771: keratitis, interstitial, in 
syphilis, 1063; care of, at birth, 1, 3; 
diphtheritic paralysis of, 806 ; early 
use, 25; ectropion of, in congenital 
ichthyosis, 875; inflammation of, in 
newly born, 87 ; in measles, 938 ; nys- 
tagmus, 676. 

Face, asymmetry of, as stigma of degen- 
eration, 771; expression of, in disease, 
34; cyanosis and oedema of, from pres- 
sure at root of lung, 1045. 

Facial paralysis at birth, 107; acquired, 
peripheral, 807 : in otitis, 900. 

Faeces, 311 ; of milk diet, 311 : of mixed 
diet, 312; incontinence of, 432. 

Fat, determination of, in milk, 133; in 
the faeces, 311; lack of, a cause of 
rickets, 241 ; in woman's milk, 131 ; 
percentages of, in modification of cow's 
milk, 182, 186, 188: symptoms from 
deficiency of, in food, 196 : symptoms 
from excess in food, 195, 197 ; function 
of, in diet, 124. 

Fatty degeneration of the newly born, 
91. 

Feeding, artificial, principles of, 178; 
rules for, 190, 199; schedule for first 
year, 190 ; versus wet-nursing, 165 ; 
breast, schedule for, 168; other than 
milk, first year, 199; difficult cases, 
first year, 201 ; Finkelstein's classifica- 
tion, 208 ; daily dietary from four- 
teen to eighteen months, 210 : for 
healthy infants, second year, 209: diffi- 
cult cases, second year, 211; from third 
to sixth year, 212 ; articles allowed, 
212; articles forbidden, 213; during 
acute illness, 214; in infants, 214; 
older children, 214 ; during periods of 
excessive heat, 355 ; by gavage, in 
acute illness, 215 ; nasal, 63 ; in acute 
intestinal indigestion and intoxication, 
357 ; methods of, in etiology of diar- 
rhoea, 344 ; mixed, indications for, 177 ; 
simple rules in, 214. 

Feet, anomalies of, as stigmata of degen- 
eration, 771. 

Fever from insufficient nourishment, 169; 
inanition, 118 (see also Temperature). 

Finger (See Dactylitis). 

Fingers, clubbing of, in congenital heart 
disease, 572. 

Finkelstein's classification of nutritional 
disturbances, 208; " food intoxication," 
361. 

Fissure of the anus, 428. 

Fistula, congenital, of the neck, 304. 

Flatulence, cause of colic, 400; in Intes- 
tinal indigestion, 396. 



INDEX. 



1090 



Flexner's serum for cerebro-spinal menin- 
gitis, 712 et seq. 

Foetal circulation, 564; endocarditis, 568. 

Foetus, evidences of syphilis in, 1054. 

Follicles, solitary (see Lymph Nodules). 

Follicular ulceration of intestine, 376. 

Fontanel, bulging of, in cerebro-spinal 
meningitis, 709; bulging of, in menin- 
geal haemorrhage, 106 ; bulging of, in 
tuberculous meningitis, 724; in hydro- 
cephalus, 745; closure of, 22; in cretin- 
ism, 766; in rickets, 251. 

Food, constituents, 123; protein, 123; 
fats, 124; carbohydrates, 125; mineral 
salts, 126; water, 126; farinaceous, a 
cause of eczema, 883; in chronic indi- 
gestion, 334; second year, 209; im- 
proper in etiology of diarrhoea, 344 ; 
of dental caries, 267; regurgitation of, 
causes and treatment, 195. 

Food diseases, 233. 

Foods, infant, 161; milk, 162; malted, 
162; farinaceous, 162; proprietary, dan- 
gers of, 122; cause of rickets, 241; 
cause of scurvy, 234 ; uses of, in chron- 
ic constipation, 404. . 

Foramen ovale, closure of, 565; function 
of, in foetal life, 564; patent, 569. 

Foreign bodies, swallowing of, 339; in the 
larynx, 471. 

Fractures, green-stick, in rickets, 244, 
253. 

Freeman's pasteurizer, 152. 

Friedreich's ataxia, 794. 

Fruit, best time for giving, 211; during 
second year, 211; allowed during third 
to sixth year, 213; forbidden during 
third to sixth year, 213. 

Furunculosis, 887 ; in diabetes mellitus, 
1092. 



Gangrene, of the face, 280 ; of intestine, 
in intussusception, 410 ; of lung, 544 ; 
in acute broncho-pneumonia, 500; in 
lobar pneumonia, 522; in scarlet fever, 
920; in measles, 938. 

Gangrenous stomatitis, 279. 

Gastralgia, 324; in malaria, 1080; in 
spinal caries, 856. 

Gastritis, acute, 327 ; etiology, 327 ; 
lesions, 327; symptoms, 329; treat- 
ment, 331 ; chronic, 331 ; ulcers in, 366 ; 
toxic (see Gastritis, Corrosive), 329. 

Gastro-enteritis (see Acute Intestinal 
Indigestion and Intoxication), 348; 
in newly born, 83. 

Gavage, 62 ; in acute illness, 215 ; in 
acute inanition, 220; in diphtheria, 
995 ; in premature infants, 13. 

Genital irritation, 645. 

Genital organs, diseases of, 631 ; anom- 
alies of, as stigmata of degeneration, 
771; care of, in newly born, 4; malfor- 
mations of, 631; female, gangrene of, 
279; females, diseases of, 636; haemor- 



rhage from, In newly bom, 102; males, 
diseases of, 634. 
Gingivitis, in dental curies, 267; hemor- 
rhagic, in scurvy, 236, 237. 

Glands, bronchial (sec LYMPH Nooks, 
Bronchial) . 

Glands, lymphatic (sec LYMPH Nooks), 
830. 

Glioma of brain, 7:;."» ; of spinal cord, 793. 

Glio-sarcoma of brain, 7.;r,. 

Glossitis, 265. 

Glottis, oedema of the, 468. 

Gonococcus, differentiation of, 638; in 
gonorrhoeal stomatitis, 278 ; In specific 
urethritis, 834; vaginitis. 687. 

Gout, its relation to eczema In children, 
879. 

Grippe (see Influenza), 1070. 

Growing pains, rheumatic, 1086. 

Growth, conditions interfering with, 30; 
of body, 15; extremities, 21; trunk, 21. 

Gumma, syphilitic (see Syphilis Le- 
sions), 1055; in syphilitic bone dis- 
ease, 871 ; of brain, 735. 

Gums, abscess of, 267; bleeding in ulcer- 
ative stomatitis, 273; inspection of, 38; 
lancing, 270; spongy and bleeding. In 
scurvy, 236, 237; in ulcerative stomati- 
tis, 273. 

Habit-spasm, 675. 

Habits, injurious, 689. 

Haematernesis, 338. 

Hematoma of the sterno-mastoid, 94. 

Haematuria, 601; in newly born, 102: in 
purpura, 826; in pyelitis. 626; in 
scurvy, 238; in tumours of kidney, 622. 

Haemoglobin, 809. 

Haemoglobinuria, 602; epidemic. 91: par- 
oxysmal, 602. 

Haemophilia, 823. 

Haemoptysis in tuberculosis, 1039. 

Haemorrhage, from stomach, 338 ; in 
haemophilia, 823 ; intra - alveolar, in 
acute broncho-pneumonia, 496; internal, 
causing sudden death, 46; intestinal, 
from tuberculous ulcer, 392; in typhoid 
fever, 1013; meningeal, causing birth 
paralysis, 747; in acquired cerebral 
paralysis, 751; in acute broncho-pneu- 
monia, 513; in convulsions, 651; men- 
ingeal, in pertussis. 958; meningeal. 
in purpura, 825 ; nasal, in diphtheria. 
986; pulmonary, in cardiac cases. 585; 
rectal, from ulcer, 430 ; in leukaemia, 
822; ih measles, 939: in pertussis. 957; 
in pernicious anaemia. 819; in purpura, 
825; in the newly born, 94: visceral. 
97; in scurvy. 233. 235; in syphilis, 
1061. 

Haemorrhagic diseases of the newly born. 
98. 

Hemorrhoids, 432; in chronic constipa- 
tion, 403. 

Hair, anomalies, stigmata of degener- 
tion, 771; in the stomach. 340. 



1100 



INDEX. 



Hand, progressive muscular atrophy of, 
796. 

Hands, anomalies, stigmata of degenera- 
tion, 771. 

Harelip, 262. 

Hay fever, 4S7. 

Head, circumference of, 21; closure of 
sutures, 22 ; closure of fontanels, 22 ; 
shape of, 22; in rickets, 250; examina- 
tion of, 34; hydrocephalic, characteris- 
tics of, 744 ; rotary and nodding spasm 
of. 070: sweating of, in rickets, 248. 

Headache, frequent, with adenoids, 201; 
varieties. 684; diagnosis, 684; treat- 
ment, 684. 

Head-banging, 063. 

Hearing, when developed, 26. 

Heart, diseases of, 564; aneurism of, 502; 
aortic disease, congenital, 570; area of 
absolute cardiac dulness, 567; of rela- 
tive dulness, 566 ; auscultation of, 38 ; 
diphtheritic paralysis of, 806; examina- 
tion of, 567; hypertrophy of, in valvu- 
lar diseases, 583 ; in measles, 038 ; in 
scarlet fever. 010; malformations of, 
568; peculiarities of, in early life, 564; 
persistent foetal conditions, 568; posi- 
tion of apex beat, 566; in infancy, 566; 
size and growth of, 565; sounds of re- 
duplication, 567 ; sudden failure of, in 
diphtheria, 088; thrombus of, ante-mor- 
tem, 505; transposition of, 571; con- 
genital anomalies of, 567; functional 
disorders of, 504 ; murmurs of, 586 ; dif- 
ferential diagnosis of, 574, 575; acci- 
dental, 503; in congenital diseases, 573; 
in chorea, 671; in marasmus, 231; 
valves, aortic insufficiency, 587; aortic 
stenosis, 587; mitral insufficiency, 586; 
mitral stenosis, 587; congenital ab- 
sence of valves, 571; tricuspid insuffi- 
ciency, 588; valvular diseases of (see 
also Endocarditis), 582; chronic val- 
vular disease of, 584; ventricle, left, 
signs of dilatation, 586; signs of hyper- 
trophy, 587; right, signs of hypertro- 
phy, 587. 

Height, 10; from birth to sixteenth year, 
20. 

Hemichorea, 672. 

Hemiplegia in acquired cerebral paral- 
ysis, 751; in birth paralysis, 747; in 
meningeal haemorrhage, 106; in cerebral 
tumour, 737; spastic, 740. 

Hepatitis, interstitial, 77; suppurative, 
437. 

Hermaphroditism, false, 632. 

Hernia, cerebri, 605 ; diaphragmatic, 115 ; 
umbilical, 112. 

Herpes labialis, 263. 

Herpetic stomatitis, 271. 

Hiccough, 677; in acute peritonitis, 444: 
in hysteria, 082. 

Hip, articular ostitis of, 850. 

Hip- joint disease (see Hip, Articular 
Ostitis of), 850. 



History-taking. 31. 

Hives (see Urticaria), 800. 

Hoarseness with adenoids, 201; in ca- 
tarrhal spasm of larynx, 462; in syph- 
ilis, 1050. 

Hodgkin's disease, S47. 

Holding-breath spells, 661. 

Home modification of milk (see Milk, 
Modification of, at Home), 186. 

Hookworm, 425. 

Hutchinson's teeth in late hereditary 
syphilis, 1062. 

Hydatids of liver, 441. 

Hydrencephalocele, 604. 

Hydrocele, 635. 

Hydrocephalus, 740; in chronic basilar 
meningitis, 728; with spina bifida, 742, 
775 ; acute (see Meningitis, Tuber- 
culous), 720-727: chronic external, 
741 ; internal, 740 ; congenital, 607 ; 
intrauterine, 606 ; syphilitic, 1056. 

Hydronephrosis, 607; traumatic, 628; 
with malformations of kidney, 607; 
with renal calculi, 627. 

Hydromyelus, 703. 

Hygiene of infancy, 1. 

Hyperesthesia, general, in cerebro-spinal 
meningitis, 707; in acute poliomyelitis, 
787; hysterical, 681; in multiple neu- 
ritis, 803 ; in scurvy, 236 ; in spinal 
meningitis, 778. 

Hypermetropia, stigma of degeneration, 
771. 

Hypertrophy, muscular pseudo-, 707. 

Hypodermic medication, 66; dosage for, 
52. 

Hypodermoclysis, indications for, 66. 

Hypospadias, 632. 

Hysteria, 680; symptoms, 680; diagnosis, 
682 ; treatment, 683. 

Hystero-epilepsy, 682. 

Ice, bag, 56; cap, 40, 56; coil, 56. 

Ichthyosis, congenital, 875. 

Icterus, 450; in epidemic hemoglobinuria, 
01; varieties in newly born, 76; in mal- 
formation of the bile ducts, 77 ; inter- 
stitial hepatitis, 77; physiological or 
idiopathic, 78; differential diagnosis, 80. 

Idiocy, 750: Mongolian, 758; amaurotic 
family, 750; cretinoid, 750. 

Ileo-colitis, acute, 365; etiology, 365; le- 
sions, 366 ; in catarrhal, 367 ; in follicu- 
lar, 370; in membranous, 372; associ- 
ated lesions, 374 ; symptoms, catarrhal 
form, 374; with follicular ulceration, 
376 ; membranous form, 372 ; diagnosis 
380 ; prognosis, 381 ; treatment, 381 et 
seq. ; broncho-pneumonia complicating 
513 ; in diphtheria, 087 ; in influenza 
1073; in measles, 037. 

Ileo-colitis, chronic, 384; lesions, 384 
symptoms, 386; diagnosis, 387; differ 
ential diagnosis, 387; prognosis, 388 
treatment, 388. 

Ileum, congenital atresia of, 114. 



INDEX. 



J 101 



Imbecility, 756. 

Impetigo, bulbous, in newly born, 02 ; 
contagiosa, 889. 

Inanition, acute, 217. 

Inanition fever, 118. 

Incubators, 12. 

Indican, in urine of cbronic constipation, 
403 ; of chronic intestinal indigestion, 
397. 

Indicanuria, 603. 

Indigestion, acute gastric, 325; etiology, 
325 ; symptoms, 326 ; diagnosis from 
gastritis, 326; treatment, 326; vomiting 
in, 319; chronic gastric, 332; etiology, 
331; lesions, 332; symptoms, in in- 
fants, 332 ; in older children, 333 ; prog- 
nosis, 332; treatment in infants, 334; 
acute intestinal, and intoxication, 348 ; 
etiology, 348; symptoms, 351; diagno- 
sis, 355 ; prognosis, 355 ; prophylaxis, 
355 ; treatment, 356 ; Finkelstein's 
" food intoxication," 359. 

Indigestion, chronic intestinal, 393 ; in 
young infants, 393; symptoms, 394; 
prognosis, 395; treatment, 395; in older 
children, 396; symptoms, 396; treat- 
ment, 398. 

Infant, care of newly born, 1; when 
premature or delicate, 10. 

Infant feeding, 163. 

Infant foods, 161. 

Infantilism, intestinal, 397. 

Infarctions, uric acid, in kidney, 610. 

Infectious diseases, the specific, 903. 

Influenza, 1070; etiology, 1070; lesions, 
1070; symptoms, 1070; with broncho- 
pulmonary complications, 1072 ; pro- 
tracted cases, 1075 ; complications and 
sequelae, 1073 ; anaemia in, 1073 ; diag- 
nosis, 1073 ; prognosis, 1074 ; treatment, 
1075 ; broncho-pneumonia, 512, 1072 ; 
epidemic, acute otitis in, 895 ; scarlatin- 
iform erythema in, 1073 ; nephritis in, 
1073. 

Inhalations, 59 ; in bronchitis, 467. 

Inheritance a factor in disease, 29. 

Injections, rectal, in ileo-colitis, 382; 
subcutaneous, of saline solution in chol- 
era infantum, 364. 

Insanity, 769 ; symptoms, 769 ; following 
typhoid fever, 1014. 

Intermittent fever, malarial, 1078. 

Intertrigo, 882; treatment, 886. 

Intestinal obstruction in newly born, 114; 
acute, from intussusception, 407. 

Intestines, diseases of, 341; amyloid de- 
generation of, 389; bacteria of, 311; 
digestion in, 310; haemorrhage from, in 
newly born, 101 ; in typhoid, 1013 ; in 
tuberculosis, 392; length, 310; mal- 
formations of, 341; obstruction, con- 
genital of, 114 ; perforation of, in tu- 
berculous ulcers, 390; in typhoid fever, 
1013; tuberculosis of, 390, 1030; eti- 
ology, 390; lesions, 391; symptoms, 392; 
treatment, 393. 



Intoxication, acute Intestinal, 848; etio!« 
ogy, 348; lesions, 850; symptoms, mild 
form, 351; rclaps.-s, 858; case* with- 
out diarrhoea, 354 ; diagno 
prognosis, 355; prophylaxis, 355; treat- 
ment, hygienic, 356; dietetic, 
medicinal and mechanical. 858 ; chol- 
era infantum, 361; etiology, 862; 
symptoms, 362; prognosis 864; treat- 
ment, 364. 

Intubation, in acute catarrhal laryngitis, 
464; in syphilitic laryngitis, 470; in per- 
tussis, 964. 

Intussusception, 407: etiology, 408 : le- 
sions and mechanism, 409; symptoms, 
410; diagnosis,. 414; prognosis, 414; 
treatment, 415; laparotomy, 415; in the 
dying, 408. 

Invagination of intestine in intussuscep- 
tion, 410. 

Iodides, elimination of, in milk, 137. 

Iritis, syphilitic, 10.17. 

Iron, preparations of, r>2. 

Irrigation, intestinal, in chronic indiges- 
tion, 399; as antipyretic, 50; of the 
colon, method of, 65. 

Ischio-rectal abscess, 431. 

Jaundice (see also Icterus), 76; ca- 
tarrhal, 435 ; chronic family, 4.',4. 

Jaw, necrosis of, from alveolar abs 
268; in gangrenous stomatitis. 280; in 
ulcerative stomatitis, 273. 

Jejunum, congenital atresia of, 114. 

Joints, diseases of, 830; hysterical affec- 
tions of, 681; in scarlet fever, 918; 
rheumatism of, 10S6; suppuration of, 
in newly born, 84; swelling of, in 
scurvy, 237; ecchymoses about, in 
scurvy, 236 ; tuberculous diseases of, 
852. 

Junket, 158. 

Kernig's sign,. 707. 

Keratitis, interstitial, in late syphilis, 
10.17, 1063. 

Kidney, diseases of, 606; acute degen- 
eration of, 611; calculi in, 627; chronic 
congestion of, 610; cystic. 607; mov- 
able, 609; granular (see NHPHBITIS, 
Chronic), 618; haemorrhage from, in 
newly born, 102; in scurvy. 238; horse- 
shoe, 607; hydronephrosis. 607; trau- 
matic, 628 ; malformations and malpo- 
sitions of. 606; malignant tumours of. 
622; nephritis, acute diffuse, 611; acute 
exudative, 611: chronic. 618; perine- 
phritis, 629; pyelitis, 624: pyoneph- 
rosis, 626; single, 607: tuberculosis 
of, 621, 1030: uric-acid infarction. 610; 
in'diphtheria. 077: in scarlet fever. 017. 

Klebs-Loeffler bacillus (see Bacillus of 
Diphtheria), 969, 991. 

Knee, articular ostitis of, so:!: Bymptoms, 
866; treatment, 867: subluxation of, 
in poliomyelitis, 7S9; swelling of, in 



1102 



INDEX. 



scurvy. 2;:7: white swelling of (see 

Knee, Articular Ostitis). 
Knee-jerk, In acquired .cerebral paralysis, 

7r>4: iu birth paralysis, 751; lost, in 

diphtheritic paralysis, 806; in multiple 

neuritis, 803; In tetany. 658. 
Knee-joint disease (see Knee, Articular 

Ostitis). 
Kuoek-knee in rickets, 254. 
Koplik's sign in measles, 931. 
Kumyss, 157. 
Kyphosis in rickets, 252 ; treatment, 200 ; 

in spinal caries, 854. 

Lactalbumin, 131, 146, 150. 

Lactation, care of breasts during, 166. 

Lactic acid milk, 157. 

Lactometer, author's, 132. 

Landry's paralysis, 795. 

Laparotomy, in acute peritonitis, 445; in 
chronic peritonitis, with ascites, 446 ; 
in intussusception, 415 ; in tuberculous 
peritonitis, 451. 

Laryngismus stridulus, 659; in rickets, 
256; with tetany, 656. 

Laryngitis, acute catarrhal, 465; catar- 
rhal, in measles, 936; chronic, 468; 
with adenoid vegetations of pharynx, 
469; tuberculous, 469; syphilitic, 469; 
with new growths of larynx, 470; spas- 
modic, 462; submucous (oedema of glot- 
tis), 468. 

Laryngeal diphtheria, 983; antitoxine in, 
998; intubation in, 1003; symptoms of, 
983. 

Laryngotomy for foreign body in larynx, 
471. 

Larynx, diseases of, 462; catarrhal spasm 
of, 462; from long uvula, 284; with 
adenoids, 292 ; diphtheria of, 983 ; for- 
eign bodies in, 471 ; intubation of, 
1003; in measles, 936; new growths of, 
470 ; spasm of, 659 ; stenosis of, sim- 
ulated by tuberculous glands, 1047 ; 
syphilis of, 469, 470, 1059 ; tubercu- 
losis of, 469. 

Lassar's paste, 885. 

Lavage (see Stomach Washing). 

Leukaemia, 820. 

Leucocytosis, 811; diagnostic value, 812; 
in diphtheria, 978; in acute meningitis, 
711. 

Lewi's method for examination of wom- 
an's milk, 133. 

Lichen urticatus (see Urticaria), 890; 
tropicus, 877. 

Limewater, in modification of cow's milk, 
183. 

Lip, eczema of, 264; perleche, 264; dis- 
eases of, 263; herpes of, 263; malfor- 
mations of, 262. 

Lisping, 686. 

Liver, diseases of, 433; abscess of, 437; 
acute yellow atrophy of, 437; amyloid 
degeneration of, 439; biliary calculi, 
441 ; cirrhosis of, 438 ; congestion of, 



437; interstitial hepatitis, 77; enlarged, 
in congestion, 437 ; in abscess, 438 ; 
in cirrhosis (early), 439; in chronic 
cardiac disease, 581; fatty, 440; in ma- 
rasmus, 229 ; functional disorders of, 
436; hydatids of, 441; in rickets, 256; 
in syphilis, 1055, 1065; in tuberculosis, 
1030; lardaceous, 439; malformations 
and malpositions of, 434 ; size and po- 
sition of, 39, 433; tuberculosis of, 1029; 
waxy, 439 ; weight of, in infancy, 433. 

Lumbar puncture, 711. 

Lung, diseases of, 472; abscess of, 543; 
abscesses of, in acute broncho-pneu- 
monia, 500; acute congestion of, in 
malaria, 1077; calcareous nodules in, 
1027; caseous degeneration of, 1025; 
collapse of, from compression, 545; 
from obstruction, 545 : in acute bron- 
cho-pneumonia, 495 ; congenital atelec- 
tasis of, 73 ; emphysema of, 547 ; acute, 
in bronchitis of infants, 476; gangrene 
of, 544; gangrene of, in lobar pneu- 
monia, 522; haemorrhages into, in new- 
ly born, 99 ; inflation of, 72 ; Carrel's 
method of, 72 ; miliary tuberculosis of, 
1033 ; peculiarities in disease, 474 ; in 
infancy and early childhood, 472 ; phys- 
ical examination of, 473 ; structure of, 
473. 

Lymph nodes, diseases of, 830 ; calcare- 
ous cervical, 843 ; bronchial, 1044 ; early 
infection in tuberculosis, 1021; enlarged 
in Hodgkin's disease, 847; in malnutri- 
tion, 222; frequency of disease of, 41; 
inflammation of (see Adenitis), 836; 
in late hereditary syphilis, 1063 ; in 
measles, 938 ; pseudo-diphtheria, 295 ; 
in scarlet fever, 916 ; simple hyperpla- 
sia of, 839 ; situation and drainage 
areas of the groups of head and neck, 
832 ; syphilitic disease of, 840 ; tuber- 
culous bronchial, 1027 ; lesions, 1021, 
1027 ; symptoms, 1031 ; cervical, tuber- 
culosis of, 841 ; mesenteric, 390, 1030 ; 
in diphtheria, 976 ; in rickets, 256 ; in 
tonsillitis, 296 ; epitrochlear, in syphi- 
lis, 1063 ; mesenteric, often enlarged, 
in marasmus, 229 ; in typhoid fever, 
1010 : tuberculosis of, 840 ; retro-phar- 
yngeal, abscess of, 284. 

Lymph nodules of intestines, ulceration 
of, 376. 

Lymphadenoma of stomach, 338. 

Lymphangioma of tongue, 263. 

Lymphatism (see Status Lymphaticus), 
832. 

Lymphocytes, 809. 

Malaria, 1075; etiology, 1076; lesions, 
1076; symptoms, 1077; diagnosis, 1082; 
prognosis, 1082; prophylaxis, 1082; 
treatment, 1082; quinine, methods of 
administration, 1083; acute pulmonary 
congestion in, 1077 ; contracted in 
utero, 1076 ; spleen in, 849. 



INDEX. 



1103 



Malformations as cause of sudden death, 

4G. 
Malnutrition, 220 ; etiology, 220 ; symp- 
toms in infants, 221 ; symptoms in older 
children, 222; diagnosis, 223; nervous 
factor in, 227; prognosis, 224; treat- 
ment in infants, 225; treatment in older 
children, 226. 
Malnutrition, marasmus, 227. 
Malt extracts, use of, in diet of nurse, 

136. 
Maltose, substitute for milk sugar, 125, 

205, 207. 
Malt soup, use of, with difficult feeding 

cases, 207. 
Mania, 769; acute, following typhoid 

fever, 1014. 
Marasmus, 227; etiology, 228; lesions, 
228 ; symptoms, 230 ; diagnosis, 231 ; 
from tuberculosis, 232, 1035 ; prog- 
nosis, 232; treatment, 232; fatty liver 
in, 440; general oedema in, 231; tuber- 

' culosis resembling, 1031. 
Massage, 66; in chronic constipation, 405; 
in malnutrition, 226; of breasts to in- 
crease milk, 172. 
Mastitis in the newly born, 113. 

Mastoid disease, cerebral abscess follow- 
ing, 899; in acute otitis, 898. 

Mastoiditis, etiology, 898; symptoms, 898; 
treatment, 901; dangers from opera- 
tion, 901. 

Masturbation, 690. 

Matzoon, 157. 

Measles, 927 ; broncho-pneumonia compli- 
cating, 512; complications and sequelae, 
936; desquamation, 933; diagnosis, 939; 
digestive system, 937 ; diphtheria in, 
937; duration of infective period, 929; 
ears in, 894, 938; eruption, 931; etiol- 
ogy, 928; eyes in, 938; German (see 
Rubella) , 943 : haemorrhage in, 939 ; 
hemorrhagic, 932 : heart in, 939 ; ileo- 
colitis, 937 ; incubation, 929 ; invasion, 
931; kidneys in, 939; larynx in, 936; 
lesions, 930 ; lungs, 936 ; lymph nodes, 
938 ; mode of infection, 930 ; mortality, 
940 ; nervous system in, 938 ; other in- 
fectious diseases in, 939 ; otitis, 938 ; 
predisposition, 928 ; prognosis, 940 ; 
prophylaxis, 941 ; pseudo-diphtheria in, 
937 ; quarantine in, 941 ; skin in, 938 ; 
symptoms, 931 ; throat, 937 ; treatment, 
942 ; tuberculosis following, 939. 

Meats, allowed from third to sixth year, 
212; forbidden from third to sixth 
year, 213. 

Meckel's diverticulum, 111, 342. 

Meconium, composition of, 311. 

Mediastinum, anterior, abscess of, 1046 ; 
tumour of, due to tuberculous lymph 
nodes, 1046. 

Mediastinitis, 577. 

Melancholia, 770. 

Melaena, 101. 

Membrane, in diphtheria, 973. 



Meningeal haemorrhage, 104, 698, tit. 
Meninges, diseases of, 694. 

Meningitis, acute, T < »< » ; ceivbio spinal. 
7oi; complications and sequeto, 710; 
course, duration and termination, 
etiology, 702; lesions. 702; lumbar punc- 
ture in, 711, 71i - .: symptoms, 704; 
nosis, 711; prognosis, 710; treatment, 
712. 
Meningitis, acute, from other causes than 
the meningococcus, 717; pneumococcus, 
717; influenza, 719; septic, 719; in newly 
born, 83; from otitis, 899; in pneu- 
monia, 513, 532; rare, in typhoid fever, 
1014. 
Meningitis, chronic basilar, 727; spinal, 

778; syphilitic, 1056. 
Meningitis, tuberculous, 720; lesions, 720; 
etiology, 721; symptoms, 72.'!; duration, 
725; diagnosis, 72.">; prognosis, 727; 
treatment, 727; lumbar puncture in, 
725. 
Meningocele of brain, 694; of cord, 77.;. 
Meningoencephalitis, 74S. 
Meningomyelocele, 774. 
Menstruation, effect on breast milk, 135. 
Mental defects, 756; classification, 7.">ti; 

diagnosis, 760; treatment, 762. 
Mercury, elimination of, in milk, 137; 
ulcerative stomatitis from, 273 ; in 
syphilis, 1068. 
Microcephalus, 697. 
Micro-organisms in cow's milk, 139; see 

also Bacteria. 
Micturition, difficult or painful, 646; fre- 
quency of, 598. 
Miliaria, 877; papulosa, S77: treatment, 

878; rubra, 877. 
Milk, cow's, 13S; average percentages of, 
181 ; bacteriological standard for, 141 ; 
handling and transportation of, 143, 
144; composition of, 144; average 
percentages in, from different breeds, 
144, 145; examination of. 145: cream, 
137 ; contaminated, cause of diar- 
rhoea, 344 ; differences from woman's 
milk, 146 ; dried milk, 156 ; essen- 
tials of, for infant feeding, 138 : formu- 
las from diluting, 188 seq. ; formulas 
reduced to percentages. 194 ; micro-or- 
ganisms in, 139; modification ol, per- 
centage or American method of, ISO, 
190: at home, 186; top-milk. 148: for- 
mulas from top-milk. 1SS teq.; sched- 
ule of percentages for first year. 186; 
schedule showing quantities and In- 
tervals of feeding, ISO; rules for vary- 
ing percentages, 190; modifications re- 
quired by particular symptoms, 195: in 
difficult cases. 205 : in summer diar- 
rhoea. 357: in acute gastric Indigestion, 
327: in chronic constipation. 4ol : pas- 
teurisation of. 150; pasteurisation of, 
at 150° V., ir>i : protein of. 123; sterili- 
sation of. at 212' l\. 152; sterilised, 
scurvy ascribed to. 234 ; tubercle ba- 



1104 



INDEX. 



cilli in. 1020 : typhoid contamination 
of. 140: condensed (see Condensed 
Milk). 154; fermented, 157, 206; pro- 
tein. ir>7 : skimmed. 206, 235, 39S : pep- 
tonised, 154 ; peptonised, use of, 154 ; 
dangers from prolonged use of, 154. 

Milk-laboratories, 184. 

Milk-sugar, 125, 182, 189; solution, how 
to prepare, 199. 

Milk, woman's. 127; physical characters 
of, 127; colostrum of, 128; daily quan- 
tity of. 128: average quantity at one 
nursing, 130; composition of, 131; pro- 
tein, 131, 134, 146; fat, 131; sugar, 
132; salts, 132; reaction, 133; specific 
gravity, 133, 134; average percentages 
of, 181; conditions affecting composi- 
tion of, 134; menstruation. 135; diet, 
135 ; drugs, 137 ; pregnancy, 137 ; elim- 
ination of antitoxine and other protec- 
tive substances, 137 ; nervous impres- 
sions, 137; examination of, 132: varia- 
tions in quality, 134; apparatus for ex- 
amining, 132, 133 ; secretion, when es- 
tablished, 127 ; how to modify quantity 
and quality, 171, 172 ; indications of 
scanty supply, 169. 

Modified milk, from milk laboratory, 184; 
schedule for feeding from birth, 190 ; 
made at home (see Milk, Modifica- 
tion of, at Home). 

Mongolian idiocy, 758. 

Monoplegia, in birth paralysis, 749 ; in 
cerebral haemorrhage, 104; in cerebral 
tumour, 738. 

Morbus coxarius (see Hip, Articular 
Ostitis of), 859. 

Morbus maculosus (see Purpura), 824. 

Morphine, dosage of, 53; dosage in con- 
vulsions, 655; hypodermically in cholera 
infantum, 364; in gastro-intestinal in- 
toxication, 360. 

Mortality at different ages, 42, 43. 

Mouth, diseases of (see also Stomatitis), 
270 seq. ; applications to, 278; care of, 
at birth, 1, 3; haemorrhage from, in 
newly born, 102; haemorrhages from, in 
scurvy, 238; malformations of, 262; 
mucous patches, in syphilis, 278, 1060 ; 
" tapir," 799 ; syringing of, 59. 

Mouth-breathing, with hypertrophy of 
tonsils, 302; with adenoids, 291; with 
retro-pharyngeal abscess, 285. 

Mucous membranes, frequency of involve- 
ment in childhood, 40; in rickets, 256. 

Mucous patches, syphilitic, 278, 1060. 

Mumps, 965 ; complications and sequelae, 
967; diagnosis, 968; etiology, 966; in- 
cubation, 966; pathology and lesions, 
965; prognosis, 968; quarantine in, 969; 
symptoms, 966; treatment, 969. 

Murmurs, cardiac (see Heart Mur- 
murs ) . 

Muscles, atrophy of, 796; in multiple, 
neuritis, 803 ; in myelitis, 779 : in polio- 
myelitis, 787 ; contractures of, hyster- 



ical, 681; in acquired cerebral paralysis, 
754 ; in birth paralysis, 750 ; develop- 
ment of, 25. 

Muscular atrophies, different types of, 
796. 

Muscular pseudo-hypertrophy, 798. 

Mustard bath, 57 ; paste, 54 ; pack, 55. 

Myelitis, 778 ; symptoms, 779 ; treatment, 
780; compression, from Pott's disease, 
780; diffuse, 779; transverse, 779. 

Myelocytes in leukaemia, 821; in diph- 
theria, 978. 

Myocarditis, 592; aneurism in, 593; toxic, 
in diphtheria, 807, 986; in scarlet fever, 
919; in syphilis, 1056. 

Myotonia, congenital (Oppenheims dis- 
ease), 800. 

Myotonia, congenital (Thomsen's dis- 
ease), 677. 

Nail-biting, 693. 

Nails in syphilis, 1061. 

Neck, cellulitis of, in scarlatina, 916 ; con- 
genital fistula of, 304 ; wry (see Torti- 
collis). 

Necrosis of bone in syphilis, 870, 871. 

Nematodes (see Worms, Intestinal), 
422. 

Nephritis, acute diffuse, 611; etiology, 
611; lesions, 612; symptoms, 613; prog- 
nosis, 615; treatment, 616; in broncho- 
pneumonia, 513; acute parenchymatous 
type, 613. 

Nephritis, chronic, 618 ; etiology, 618 ; 
lesions, 618 ; symptoms, 619 : of the 
parenchymatous type, 619; of the in- 
terstitial type, 619 ; diagnosis, 620 ; 
prognosis, 620 ; treatment, 620 ; chronic 
diffuse, with hydronephrosis, 609; 
chronic interstitial, syphilitic, 1057 : in 
diphtheria, 977 ; interstitial (see Neph- 
ritis, Chronic), 619; post-scarlatinal, 
917. 

Nerves, peripheral, diseases of. 800. 

Nervous impressions, effect of, on breast 
milk, 137. 

Nervous system, diseases of, 647 ; general 
hygiene of, 5 ; peculiarities of, in 
childhood, 647. 

Neuritis, multiple, 800; after diphtheria, 
804; in malaria, 1080; optic, in acute 
meningitis, 708; in cerebral tumour, 
738; with cerebral abscess. 733. 

Newly born, diseases of, 68 : acute in- 
fectious diseases of, 80; acute pyogenic 
diseases of, 81: atelectasis, congenital, 
73; asphyxia of, 68; blood in, peculi- 
arities of, 809; care of, 1; diseases or 
accidents at birth. 30; dermatitis ex- 
foliativa in, 875; facial paralysis in. 
107; fatty degeneration of, 92; haemor- 
rhages in, 94; hemorrhagic disease of. 
98; hyperpyrexia in, 118; inanition 
fever in, 118: icterus in, 76: infection 
of, 30 ; malformations of, 30 : mastitis 
in, 113 : ophthalmia of, 87 ; pemphigus 



INDEX. 



1105 



in, 92; peritonitis in, 442; sclerema in, 
117; skin of, 873; ulcer of stomach in, 
336. 

Nightmare, 688. 

Night-terrors, 688. 

Nipples, care of, during lactation, 166 ; 
fissure of, haematemesis from, 338; rub- 
ber, choice of, 198; care of, 198. 

Nodding spasm of head, 676.. 

Nodes, lymph (see Lymph Nodes), 830. 

Nodules, subcutaneous tendinous, in rheu- 
matism, 1088. 

Noma of face (see Stomatitis, Gangre- 
nous), 279; of vulva, 640. 

Nose, diseases of, 454; deformities of, 
in hereditary syphilis, 460; difficulty in 
blowing, with adenoids, 290; diphtheria 
of, 979; discharge from, with adenoids, 
290; foreign bodies in, 457; haemorrhage 
from, 460 ; in newly born, 101 ; in 
scurvy, 238 ; in hereditary syphilis, 459, 
1056 ; in late syphilis, 1064 ; polypi in, 
458 ; pseudo-diphtheria of, 295 ; sprays 
for, 58 ; syringing, 58. 

Nurse, requisite qualities in, 10; wet (see 
Wet-nurse). 

Nursery, temperature and ventilation 
of, 9. 

Nursing, during acute illness, 214; dur- 
ing first days of life, 167; hours for, 
in newly born, 167; during illness, 176; 
importance of good habits of, 167 ; un- 
successful, symptoms of, 168 ; mater- 
nal, contra-indications for, 166. 

Nursing-bottles, choice of, 198; care of, 
198. 

Nutrient, enemata, 65. 

Nutrition, derangements of, 216; acute 
inanition, 217; malnutrition, 220; ma- 
rasmus, 227; faulty, diseases due to, 
233; importance in paediatrics, 122. 

Nystagmus, 676: in cerebral haemorrhage, 
106; in hydrocephalus, 745; in tuber- 
culous meningitis, 723; stigma of de- 
generation, 771; with tumour of crura 
cerebri, 738. 



Oatmeal water, 161. 

O'Dwyer's intubation set, 1003. 

CEdema, in acute diffuse nephritis, 613, 
614 ; in anaemia, 814 ; in chronic neph- 
ritis, 619 : in cardiac disease, 572 ; in 
leukaemia, 822; of face from pressure at 
root of lung. 1045; general, in maras- 
mus, 231. 

CEdema glottidis, 468; rare in acute ca- 
tarrhal laryngitis, 465; in corrosive 
oesophagitis, 305; in quinsy, 301. 

Oesophagitis, acute, 305; catarrhal, 305; 
corrosive, 305. 

Oesophagus, diseases of, 304 ; abscess be- 
hind, 305; congenital narrowing of. 
304; congenital obstruction in, 304; 
diphtheria of. 975; malformations of, 
304 ; stricture of, 304 : thrush in, 304. 
71 



Oil enemata, 65; in chronic constipation, 

406. 
Omphalitis in newly born, 82. 

Omphalomesenteric duet. 111, '.',Vl. 

Onychia, syphilitic, lor.!*. 

Ophthalmia, gonorrheal, 87; in newly 
born, 87: treatment, 88. 

Opisthotonus, cervical, 678; hysterical, 
682; in cerebro-splnal meningitis, To.".; 
in birth paralysis, 750: In meningeal 
haemorrhage, 10(5; in chronic basilar 
meningitis, 728; in marasmus, 231; in 
tuberculous meningitis, 724. 

Opium, elimination of, in milk, 137; in 
acute intestinal indigestion and in- 
toxication, 360, 364 ; in bronchitis, 481 ; 
preparations and dosage of, 53. 

Oppenheim's disease, 800. 

Optic nerve, atrophy of, in cerebral tu- 
mour, 736. 

Orchitis, in mumps, 968; in specific ure- 
thritis, 635; syphilitic, 1057; tubercu- 
lous, 1030. 

Orthopncea, in chronic valvular disease, 
585; in functional disorders of the 
heart, 594. 

Osteo-myelitis, acute (see Arthritis, 
Acute), 850; in newly born, 84; tuber- 
culous, 865; symptoms, 866; diagnosis, 
867; treatment, 867. 

Osteo-periostitis, chronic, syphilitic, 869. 

Ostitis, primary, followed by joint dis- 
ease, 853; simulated by scurvy, 239. 

Otitis, acute, 894; etiology, 894; lesions, 
895; symptoms, 896; complications and 
sequelae, 898; treatment, 900; cerebral 
abscess in, 732, 899; thrombosis of 
lateral sinus in, 899; facial paralysis 
in, 900; labyrinth in, 899; mastoid dis- 
ease in, 898; meningitis in, 899; 
chronic, in late syphilis, 1064; reflex 
cough from, 484; frequent attacks of, 
with adenoids, 291; in influenza, 1075; 
in scarlet fever, 916; in syphilis, 1057; 
in typhoid fever, 1014. 

Overlying, causing death by asphyxia, 46. 

Oxyuris vermicularis (see Worms, Intes- 
tinal), 423. 

Ozaena, syphilitic, 460, 1064. 

Pachymeningitis, acute, 698; chronic (in- 
ternal), 698; syphilitic, 1056; meningeal 
haemorrhage from, 699; haemorrhagic, 
698; pseudo-membranous, 698. 

Pack, cold, 4'.); hot, 56; mustard, 55. 

Palate, cleft, 262; deformities of, stig- 
mata of degeneration, 771; diphtheritic 
paralysis of, 805; hard, ulceration of, 
275; in late syphilis. 1064; soft, lesions 
of, in hereditary syphilis. 460. 

Pancreas, ferments of, 310; syphilis of. 
1057; tuberculosis of, 1030. 

Paracasein, formed from casein in stom- 
ach digestion. 147. 

Paralysis, ascending, 795: atrophic (see 
Poliomyelitis), 782; birth. 104, 747; 



1106 



INDEX. 



atrophy and sclerosis following, 74!); 
meningo - encephalitis, 748; secondary 
degenerations following, 74!) ; symp- 
toms, 74!); i:rb's. 109; facial. 107. 807; 
in acute otitis. 900; hysterical. 682; in 
compression-myelitis, 780: In multiple 
neuritis. SO'J: in myelitis. 770: Landry's. 
705; of face in newly horn. 107: of the 
upper extremity in newly horn. 100; 
peripheral. 104 (see also Neuritis, 
Multiple), 800: post - diphtheritic, 
087 : pseudohypertrophic, 797 ; simu- 
lated by scurvy, 237. 

Paralysis, infantile cerebral, 104, 747; 
acute acquired, 751: birth, 747; of 
intra-uterine origin, 747; varieties and 
symptoms, 747, 749, 753 ; prognosis, 
754: diagnosis, 755; treatment, 755. 

Paralysis, infantile spinal (see Polio- 
myelitis), 782. 

Paraplegia, Pott's (see Myelitis,, Com- 
pression), 780; spastic, 747. 

Paregoric, dosage of, 53. 

Parotitis, epidemic (see Mumps), 965. 

Pasteurised milk, 150. 

Pathology, general considerations of, 40. 

Pavor nocturnus, 688. 

Peliosis rheumatica, 829. 

Pelvis, deformities of, in rickets, 252. 

Pemphigus, gangrenosa, 888; syphilitic, 
1057; in newly born, 92. 

Pepsin in stomach secretion, 309. 

Peptonised milk, preparation of, 154. 

Percentages, formulas reduced to, 194; 
of ingredients in milk formulas, how to 
calculate them, 187 seq. 

Pericarditis, 576; acute, in broncho-pneu- 
monia, 513; chronic, with adhesions, 
581; diagnosis, 579; dry, 577; external, 
577; in newly born, 83; in rheumatism, 
577, 578, 1087; mediastinal, 577; prog- 
nosis, 579; purulent, 577; sero-fibrinous, 
577; tuberculous, 577; with effusion, 
577; with effusion of blood, 577; with 
lobar pneumonia, 523, 532; with pleuro- 
pneumonia, 538; with transudation of 
serum, 576. 

Pericardium, congenital absence of, 571; 
tuberculosis of, 1029. 

Perinephritis, 629; acute peritonitis com- 
plicating, 443. 

Peritonaeum, diseases of, 441; haemor- 
rhage into, in newly born, 98; in tuber- 
culosis, 1030. 

Peritonitis, acute, 442; etiology, 442; 
lesions, 443; symptoms, 444; treatment, 
445; chronic, non-tuberculous, 445; 
with ascites, 445; foetal, cause of mal- 
formations, 342; in intussusception, 
414 ; in newly born, 82 ; in suppurative 
appendicitis, 410; pelvic, from gonor- 
rhoea, 638; tuberculous, 447; miliary, 
with general tuberculosis, 447; miliary, 
with ascites, 447; fibrous form, 448; 
with intestinal ulcers, 391; with lobar 
pneumonia, 532. 



Perspiration (see Sweating), 875. 
Pertussis, 954; broncho-pneumonia in, 

!).">!); complications. 058; convulsions, 
960; diagnosis, 961; etiology, 955; 
hemorrhages in, 958; ileo-colitis in, 
900; incubation, 956; infective period, 
956; lesions, 956; leucocytosis in, 961; 
paralysis in, 960; predisposition to, 
955 ; prognosis, 901 ; prophylaxis, 962 ; 
symptoms, 956; treatment, 902. 

Peyer's patches, in typhoid fever, 1010; 
swollen, in acute ileo-colitis, 367; tuber- 
culosis of, 391; ulceration of, in ileo- 
colitis, 370. 

Pharyngitis, acute, 282; uvulitis in, 283; 
chronic catarrhal, syphilitic, 1056. 

Pharynx, diseases of, 282; adenoid vege- 
tations of vault, 288, 457; with ade- 
nitis, 836; diphtheria of, 973; diph- 
theritic paralysis of, 805; lesions of, in 
hereditary syphilis. 459; reflex cough 
from, 484; retro-pharyngeal abscess, 
294: syphilitic ulceration of, 1056; 
syringing of, 59. 

Phimosis, 631; reflex phenomena from, 
632. 

Phlebitis, of dural sinuses, 730. 

Phosphorus in rickets, 260. 

Photophobia, in influenza. 1071; in mea- 
sles, 931 ; in tuberculous meningitis, 
723. 

Phthisis, chronic, 1027, 1044. 

Physical examination of the child, 33. 

Pica, 693. 

Pick's paste, 886. 

Pinworms (see Worms, Intestinal), 
423 ; proctitis from, 429. 

Plasmodium malariae, 1076. 

Pleura, effusion into, in acute nephritis, 
614; tuberculosis of, 1023, 1029. 

Pleurisy, 549; dry, 549; in acute broncho- 
pneumonia, 500; purulent (see Empy- 
ema), 554; tuberculous, dry form, 549; 
with lobar pneumonia, 501; with serous 
effusion, 551; Grocco's sign in, 552. 

Pleuro-pneumonia, 537; pericarditis in, 
576, 578. 

Pneumococcus, in broncho-pneumonia, 491, 
492; lobar pneumonia, 491; peritonitis, 
443; diphtheria, 972, 985; empyema, 
554 ; acute meningitis, 717 : malignant 
endocarditis, 591 ; pericarditis, 576. 

Pneumonia, 489; anatomical varieties and 
classifications of, 489; broncho- (see 
Broncho - pneumonia. Acute), 492; 
catarrhal (see Broncho - pneumonia, 
Acute), 492; chronic interstitial (see 
Broncho-pneumonia, Chronic), 540; 
in newly born, 80; in typhoid fever, 
1013; sources of infection. 492; varie- 
ties, classification, 492; hypostatic, 
539; in marasmus, 229; lobular (see 
Broncho - pneumonia, Acute), 492; 
pleuro- (see Pleuro-pneumonia), 537; 
syphilitic, 1055; tuberculous, 1035 
(see also Tuberculosis, Pneumonia) ; 






INDEX. 



1107 



course, duration, termination, 1035; 
diagnosis, 1030; physical signs, 1036; 
chronic, 1041. 

Pneumonia, lobar, 520; etiology, 520: fre- 
quency of. 401. 520; complicating influ- 
enza, 1072: complications, 531: course. 
523; abortive, 324: cerebral, 524; diag- 
nosis, 532 : lesions, 521 ; lysis, fre- 
quency of, 527 : pathological differen- 
tiation from broncho-pneumonia, 490 ; 
physical signs, 529 ; prognosis, 534 : 
symptoms, 523 : cerebral, 528 : termi- 
nation, 523 : treatment, 535. 

Pneumothorax in pulmonary tuberculosis, 
1029. 

Pock, in vaccinia. 951; in varicella. 047. 

Poisons, gastritis from, 327, 329. 

Poisoning, stomach-washing in, G2. 

Porencephalitis, acute, causing cerebral 
paralysis, 752. 

Poliomyelitis, acute, 782; etiology, 783; 
lesions, 785; diagnosis, 790: extent and 
distribution of primary paralysis, 789; 
electrical reactions, 789 ; prognosis, 791 ; 
treatment, 792. 

Polydipsia in diabetes insipidus, 605; 
mellitus, 1091. 

Polypi, nasal, 458; rectal, 432. 

Polyuria, 605; hysterical, 682: in diabetes 
insipidus, 605: mellitus, 1091. 

Porencephalus, 697. 

Pott's disease (see Spixe, Caries of), 
854 : cervical, causing torticollis, 679 ; 
reflex cough in, 484. 

Powders for skin. 4. 

Praecordia, bulging of, 566, 587. 

Pregnancy, effect on woman's milk, 135, 
137; effect on nursing child, 175. 

Premature infants, management of, 12: 
results with, 14. 

Prematurity, cause of marasmus, 228. 

Prepuce, adherent, 631. 

Prickly heat, 877. 

Proctitis, 429. 

Prognosis, general consideration of, 42. 

Progressive muscular atrophy, hand type, 
796: peroneal type, 797. 

Prolapsus ani (see also Rectum, Pro- 
lapse of), 426; from proctitis, 430; 
in ileo-colitis, 375 ; in membranous ileo- 
colitis, 379. 

Prophylaxis, general consideration of, 47. 

Protein, determination of, in milk. 134: 
function in diet, 123: in the faeces, 312: 
of woman's milk, 131 : of cow's milk. 
146; percentages of, in modification of 
cow's milk. 188, 193: vegetable. 124. 

Protein milk, 157. 

Pseudo-diphtheria (see Membranous Ton- 
sillitis, 295). 

Pseudo-hypertrophic paralysis. 797. 

Pseudo-paralysis in rickets, 255; in scurvy, 
237; in syphilis, 868, 1061. 

Psoas abscess in spinal caries. 858. 

Puberty, delayed, stigma of degeneration, 
771; in cretins, 766; in syphilis, 1065; 



effect of, on heart In valvular dl 
585, 588; reflei cough of, 484. 

Pulse, examination of, 85; In early life, 
565. 

Purpura, 824; arthritic, 829; blood In 
fulmlnans, 828; gangrenous, 828; nem 
atemesls In, sl'7: hemorrhagica, v_'7; 
Henoch's, 828; primary, sit, ; rheumat' 
lea, 829; simplex, 824, 827; symptomatic, 
S24: cachectic, 824; Infections, 824; neu- 
rotic, 825; mechanical, 825; toxic, 

Pyaemia, in newly born, 81; of bone 
autiikitis. Acute), 850. 

Pyelitis. C.-J4. 

Pyelo-cystitis, 024. 

Pyelo-nephritis, 603. 

Pylephlebitis, 437; cause of hepatic ab- 
scess, 437. 

Pylorus, hypertrophic stenosis of, 813; 
etiology, 313; symptoms, 313; diagnosis, 
316; treatment, 317: dilated stomach In, 
335. 

Pyogenic diseases, acute, in newly born, 
81; general symptoms, 85; prophylaxis. 
86; treatment, 87. * 

Pyonephrosis following pyelitis. 624. 

Pyopneumothorax in pulmonary tubercu- 
losis, 1029. 

Pyuria, 602; in pyelitis, 025. 

Quincke's lumbar puncture, 711. 
Quinine, dosage, 1084; methods of admin- 
istration, 10S3; sea rla Uniform rash. 922. 
Quinsy, 300. 

Rachitis (see Rickets), 241. 

Reaction of degeneration, in Erb's paral- 
ysis. 110 : in facial paralysis. 108 : in 
multiple neuritis, 803: in poliomyeli- 
tis. 789, 792. 

Rectal injections (see Knkmata. 65) : 
astringent, 383: oil, 406; saline. 

Rectal polypus, 432. 

Rectum, diseases of, 426; administration 
of drugs by, 05: atresia of. .".41: con- 
genital obstruction of. 114 ; feeding by, 
65: haemorrhage from ulcers of. 430; 
inflammation of (sec PROCTITIS), 429; 
malformations of. 341 ; prolapse of. 
426; ulcers of. 430. 

Regurgitation of food, causes of. in young 
infants. 105: nasal, in diphtheria, s <"'. 
981, 989. 

Remittent fever, malarial. 1077. 

Renal calculi. »">27: renal colic. 628. 

Rennet, ferment in digestion. 309. 

Respiration, artificial, methods of, 7 1 
Cheyne-Stokes, in cerebrospinal menin- 
gitis. 709; in meningitis, tuberculous. 
723: noisy at night with adenoids, 290; 
paralysis ..f. in diphtheria, 808; rapid- 
ity and characteristics of. 472: in pul- 
monary tuberculosis, 1042. 

Respiratory system, diseases of. 454, 

Rheumatism, 1085; symptoms, 1086; di- 
agnosis, 1089; treatment. 1090; chorea 



1108 



INDEX. 



in. 870, loss : endocarditis in. 582, 

10S7 : erythema in. 1089 : purpura in. 
829, 1089; scarlatinal, 918; simulated 
by scurvy, 239 : subcutaneous tendinous 
nodules. 1088; tonsillitis in, 299, 1088; 
torticollis in. 079. 1087. 

Rhinitis. Chronic, 457; simple, 4.">S: syphil- 
itie, 450: hypertrophic, cause of asthma, 
4S:>. 

Rhino-pharyngitis, acute, 454: in influ- 
enza. 1072: with adenoids, 290. 

Rhino-pharynx, diphtheria of, 974, reflex 
cough from irritation of, 4S4 ; simple 
catarrh of, in acute otitis. S95. 

Ribs, beading of, early symptoms in rick- 
ets. 251: resection of, in empyema, 561. 

Rice water, 161. 

Rickets, 241; etiology, 241; lesions, 243; 
symptoms, 24S: course and termination, 
256; acute, 257 (see also Scorbutus), 
233 ; congenital, 257 ; convulsions in, 
248 ; diagnosis, 257 ; from scurvy, 239, 
258 ; prognosis, 258 : treatment, 259 ; of 
deformities, 260 ; dilatation of stom- 
ach in. 335 : late, 257 ; spleen in, 248, 
849. 

Ringworm of scalp, 893. 

Rotheln (see Rubella), 943. 

Roundworms (see Worms, Intestinal), 
422. 

Rubella, 943; diagnosis, 945; eruption, 
944; incubation, 944; symptoms, 944; 
treatment, 946. 

Rubeola (see Measles), 927. 



Saccharomyces albicans in thrush, 275. 

Saline solution, as rectal injection, 382; 
subcutaneous injection of, in cholera in- 
fantum, 364 ; in acute inanition, 219. 

Saliva, 308. 

Salivation, in mumps, 967 ; in ulcerative 
stomatitis, 273. 

Salvarsan, 1069. 

Salts, inorganic, in modification of cow's 
milk, 183; mineral, function of, in diet, 
126; of cow's milk, 147; of woman's 
milk, 132. 

Sarcoma, of brain, 735; of kidney, 622; 
of spinal cord, 793 ; of stomach, 337. 

Scabies, 891. 

Scalp, pustular eczema of, 886; ringworm 
of, 893 ; seborrhcea of, 878. 

Scarlatina (see Scarlet Fever), 902. 

Scarlatiniform erythema, causes of, 922. 

Scarlet fever, 902; albuminuria in, 917; 
angina in, 914; blood in, 919; cellulitis 
in, 916; complications and sequelae, 914; 
desquamation, 909: diagnosis, 921; diph- 
theria in, 915, 920; disinfection after. 
924; duration of infective period, 905; 
eruption, 907: etiology, 904; heart in, 
919; incubation of, 905: invasion, 907; 
joints in, 918: kidneys in, 917: lesions, 
906; lymph nodes in. 916: mode of in- 
fection, 905 ; mortality in, 922 ; myocar- 



ditis in. 919: nervous system in, 920; 
other infectious diseases with. 020 ; oti- 
tis in. OK! : predisposition to. 904; prog- 
nosis. 922; prophylaxis. 923; quarantine 
in. 923: relapses, recurrences, and sec- 
ond attacks, 914; symptoms. 907, 914; 
surgical, 913; throat in. 914; treatment, 
925. 

Schultze's method of inducing artificial 
respiration. 71. 

Sclerema, 117; in cholera infantum, 3C3. 

Scorbutus, 233 ; etiology, 233 : lesions, 
235 : symptoms, 236 : diagnosis, 239 ; 
treatment, 240 ; rickets with, 239 ; sto- 
matitis in, 274. 

Scrofula (see Adenitis, Tuberculous), 
840: (see Tuberculosis). 

Scurvy (see Scorbutus), 233. 

Seborrhoea, 878. 

Senses, special, development of. 25. 

Sepsis in newly born, 81. 

Serous membranes, frequency of disease 
of, 40. 

Serum-therapy of diphtheria, 997. 

Serum-therapy of cerebro-spinal meningi- 
tis, 712, seq. 

Shiga bacillus (see Bacillus of Dysen- 
tery), 349, 366. 

Shower bath, 57. 

Sight, when developed. 25. 

Singultus, 677. 

Sinuses of dura mater, thrombosis of, 
729; lateral, in otitis. 899. 

Skin, diseases of, 875: anomalies of, as 
stigmata of degeneration, 771: of newly 
born, 875; care of, in newly born, 4. 

Skull, asymmetry of, in birth paralysis. 
751 ; in rickets, 249 : sutures, separa- 
tion of, in hydrocephalus, 743 ; syphi- 
litic nodes on, 872. 

Sleep, disorders of, 686: disturbed, 7, 
688; with hypertrophy of tonsils, 302: 
in intestinal indigestion, 396: in rick- 
ets, 248; with adenoids. 290: excessive, 
689 ; inspection during, 33 proper peri- 
ods of, 5. 

Sleeplessness, C86. 

Smallpox, protection against (see Vac- 
cination), 948. 

Smegma, 631, 634. 

Smell, sense of, when developed. 27. 

Snoring, with adenoids, 290: with hyper- 
trophied tonsils, 302. 

Snuffles, syphilitic, 459. 1058. 

Spasm, carpo-pedal (see Tetany i, 656 ; of 
larynx. 659; habit, 675: nodding, of the 
head, 676; rotary, of the head, 676: 
vesical, 045. 

Speech, disorders of, 685: when acquired, 
27. 

Spina bifida, 773 ; with congenital hydro- 
cephalus. 742. 

Spinal cord (see Cord, Spinal i. 772. 

Spine, angular curvature of. in caries, 
857; caries of. 854: symptoms. 855; 
physical examination, S56: diagnosis, 



INDEX. 



1109 



858; treatment, 859; causing compres- 
sion of cord, 780; curvature of, in hip 
disease, 862 ; hysterical affections, ref- 
erable to, 681 ; in rickets, 2r>i* ; lateral 
deviation of, 858; Pott's disease of (see 
Spine, Caries of), 854. 

Spirochaeta pallida, in syphilis, 1052. 

Spleen, diseases of, 848; amyloid degen- 
eration of, 850; enlargement of, 849; 
in acute disease, 897; in chronic car- 
diac disease, 581; in chronic disease, 
849; in cirrhosis of liver, 438; in leu- 
kaemia, 821; in malaria, 1080; in pseudo- 
leukaemic anaemia, 817 ; in rickets, 248, 
849; in simple anaemia, 814; in typhoid 
fever, 1011 ; with amyloid liver, 439 ; in 
diphtheria, 977; in hereditary syphilis, 
1055; in late syphilis, 1065; in tuber- 
culosis, 1040; new growths and tumours 
of, 850; position and methods of exami- 
nation, 848; weight, 848. 

Sponge bath, cold, 57. 

Sponging, cold, 49. 

Spray, nasal, 58; steam, 60. 

Sprue (see Thrush), 275. 

Sputum, means of obtaining, for examina- 
tion, 1043. 

Stammering, 685. 

Staphylococcus, in furunculosis, 887 , in 
acute broncho-pneumonia, 591 ; in diph- 
theria, 972; in empyema, 554. 

Starch, in the faeces, test for, 312; ob- 
jections to, as food of young infants, 
125. 

Status lymphaticus, 46, 832. 

Stenosis, laryngeal, in acute catarrhal 
laryngitis, 465; in syphilitic, 470; of 
pylorus, 319; dilated stomach in, 335. 

Stercoraceous vomiting, in intussuscep- 
tion, 411. 

Sterilisation of milk, 149; changes pro- 
duced by, 149; at 212° F., 150; at low 
temperature, 151; indications for, 153; 
limitations of, 153; methods of, 152. 

Sterno-mastoid, haematoma of, 94 ;' spasm 
of (see Torticollis). 

Stigmata of degeneration, 771. 

Stimulants, 52; alcoholic, 51; indications, 
51; contra-indications, 51; administra- 
tion, 51. 

Stomach, diseases of, 308; absorption 
from, 310; bacteria of, 310; capacity 
of, 309 ; congestion of, in acute intes- 
tinal indigestion and intoxication, 350 ; 
development of, 309 ; digestion in, 309 ; 
digestion in, 309 ; dilation of, 335 ; in 
chronic gastric indigestion, 332 ; in 
rickets, 255 ; haemorrhage from, 338 ; 
in newly born, 101 ; in scurvy, 238 ; in- 
flammation of (see Gastritis), 328; 
malformations and malpositions of, 
312 ; round ulcer of, in chlorosis, 815 ; 
tuberculosis of, 1030 ; tumours of, 337 ; 
ulcer of, 336 ; in newly born, 336 ; 
from acute gastritis, 337 : tuberculous, 
337 ; round, perforating, 337. 



Stomach washing, in acute gastritis, 
in acute Indigestion, 320; in chronic In- 
digestion, 334 ; in acute intestinal Indi- 
gestion and Intoxication, 358 : method, 

62 ; indications for, 83. 
Stomatitis, aphthous t see Herpetic sto- 
matitis), ut l ; catarrhal, uto ; in 
measles, «.t:;7 : diphtheritic, 27s, 975 ; 

follicular (see HERPETIC STOMATITIS), 

271 ; gangrenous, 279; gonoooccus, 278; 

herpetic, 271 ; in newly born, M ; para- 
sitic (see THBUSH), 27.". ; syphilitic, 
278 ; ulcerative, 272 ; vesicular 
Herpetic Stomatitis), 271. 

Stone, in the kidney, 627; in the bladder, 
646. 

Stools, blood in, from ulcer of stomach, 
337; in catarrhal ileo-colitis, 374, :;7»i: 
in membranous ileo-colitis, 370; in in- 
tussusception, 414; in purpura, S27; fat 
in, 197, 351; green, explanation of, 351; 
in acute intestinal indigestion and in- 
toxication, 351, 353; in cholera infan- 
tum, 362; in acute ileo-colitis, .'174. :;7t;. 
377, 379; indication of Improper feed- 
ing, 197; mucus in, in malnutrition, 
223. 

Strabismus, in tuberculous meningitis, 
724 ; stigma of degeneration, 771 ; with 
tumour of crura cerebri, 738. 

Streptococcus, angina (see Membranous 
Tonsillitis), 295; pyogenes, in acute 
broncho-pneumonia, 491; in complica- 
tions of scarlet fever, 915; in derma- 
titis gangrenosa, 888; in diphtheria. !)72, 
976, 985; in empyema, 554; in measles, 
937; in peritonitis, acute, 443; in pseudo- 
diphtheria, 295; in scarlet fever, 904. 

Stridor, in catarrhal spasm of larynx, 
463; in acute catarrhal laryngitis, 4(i<;; 
congenital, 116. 

Strophulus (see Miliaria RUBRA), 877; 
(see Urticaria), 890. 

Stupe, turpentine, 54. 

Stuttering, ,685. 

Sucking, 308; as a bad habit, 689. 

Sudamina, 877. 

Sudden death, chief causes of, 44. 

Sugar, cane, derivatives in digestion. 311; 
substitute for milk-sugar, 12.~>, 182; milk, 
determination of, 134; percentage of. 
in woman's milk, 132; milk, derivatives 
in digestion, 311; percentages of. in 
modification of cow's milk, 182; solu- 
tions, rules for making, 1S7. 188; stools 
in difficult digestion of. 395 : symptoms 
of excess of, in food, 19."., 197, 

Summer diarrhoea, 348. 

Suppositories, in chronic constipation. 
405; medicated, 40.1; proctitis from Long 
use of, 42i>. 

Suprarenal capsules, in syphilis. 1057;- In 
tuberculosis, 1030; hsemorrhage Inti 

Sutures, closure of. 22; premature ossifi- 
cation of, 2.".: separation of, in hydro- 
cephalus, 743. 



1110 



INDEX. 



Sweating, in infants. ST."); of head in 
rickets. 248: in tuberculosis, 1039. 

Symptomatology, general considerations, 
31. 

Synovitis, acute purulent (.see Arthritis. 
AerrKi. 850; scarlatinal, 918. 

Syphilis. 1052; acute epiphysitis in, 867; 
acute osteo-myelltls in. 868; bone le- 
sions in. 807: chronic osteo-periostitis 
in. 809: dactylitis in, 873: of larynx, 
409: pseudo-paralysis in, 868: spleen in, 
849; acquired. 1052. 

Syphilis, hereditary, 1053; adenitis in, 840; 
bones, 1054 : Colles's law, 1054 ; com- 
mnnicability of, 1054 ; diagnosis, 1065 ; 
etiology, 1053 : evidences of, in foetus, 
1057; haemorrhages, 1061; lesions, 1054; 
prognosis, 1066: prophylaxis. 1067; pseu- 
do-paralysis, 1061; rhinitis of. 459; 
spleen, 1055; symptoms, 1057: at birth, 
77. 1057; treatment, 1068; salvarsan, 
1069; late hereditary, 1063; bones, 1063; 
skin, 1064; liver, 1055; spleen, 1065; 
teeth, 1062; tertiary, chronic laryngitis 
in. 469: intubation for, 470. 

Syringe, nasal, 58 ; for antitoxine, 998. 

Syringing, nasal, 58; of mouth and 
pharynx, 59. 

Syringo-myelia, 793. 

Syringo-myelocele, 775. 



Tachycardia, 594. 

Taenia, cucumerina or elliptica, 420; nana, 
420 ; saginata or medio-carnellata, 420 ; 
solium, 420. 

Tapeworms, 420. 

Taste, when developed, 27. 

Teeth, 27; eruption of first set, 28; per- 
manent set, 29; presence of, at birth. 
28 ; care of, 3 : decayed (see Dental 
Caries, 266) ; cause of adenitis, 836 ; 
delayed, in rickets, 255 ; grinding of, 
in intestinal indigestion, 396 ; Hutch- 
inson's, in syphilis, 1062. 

Temperature, at birth, 35; in childhood, 
36; subnormal, 36; raised by artificial 
heat, 30; variations of, in health, 36; 
general consideration of, 49; of nursery, 
9. 

Tenesmus, from proctitis, 429: in intus- 
susception, 413; in membranous ileo- 
colitis, 379; treatment of, 283. 

Tent for inhalation and vapourisation, 59. 

Testicle, retraction of, with renal calculi, 
627; syphilis of, 1057: tuberculosis of, 
1030 ; undescended, 633. 

Tetanus, in the newly born, 89. 

Tetany. 050. 

Therapeutics, general consideration of, 
48. 

Thomson's disease, 077. 

Thoracoplasty, 563. 

Thorax, description of, 472 ; measure- 
ments of, 20, 24 ; causes of deformity 
of. 24. 



Threadworms (see Worms, Intestinal), 
423. 

Throat, diseases of (see Pharynx and 
Tonsils) ; importance of inspection of, 
38. 

Thrombosis. 595 ; cachectic, of dural si- 
nuses. 729 ; in diphtheria. 977, 986 ; in 
infectious diseases, 597 ; inflammatory, 
of dural sinuses, 730 ; of internal 
jugular vein, 597 ; of lateral sinus in 
acute otitis, 899 ; of sinuses of dura 
mater, 730 ; of the aorta, 597 ; of the 
vena cava, 597 ; septic, of dural si- 
nuses, 731. 

Thrush, 275. 

Thymus, abscess of, syphilitic, 1057 ; 
enlargement of, causing convulsions, 
47 ; in status lymphaticus, 832 ; tuber- 
culosis of, 1030. 

Thyroid extract in cretinism, 767. 

Thyroid gland, congenital, absence of, in 
cretinism, 768. 

Tibia, deformities of, in rickets, 254 ; 
enlarged epiphyses in rickets, 244 ; 
sabre-blade deformity in syphilis, 
870. 

Tinea tonsurans, 893 ; treatment, 893. 

Toes, clubbing of, in congenital heart dis- 
ease, 572. 

Tongue, diseases of, 264 ; bifid, 263 ; con- 
genital hypertrophy of, 263 ; epithelial 
desquamation of, 265 ; geographical, 
265 ; inflammation of, 265 ; malfor- 
mations of, 263 ; ulcer of frenum, 
266. 

Tongue-sucking, 693. 

Tongue-swallowing, 266. 

Tongue-tie, 263. 

Tonics, 52. 

Tonsils, diseases of, 294 ; anatomy of, 
294 ; chronic hypertrophy of, 301 ; 
diphtheria of, 975, 981 ; hypertrophy 
of, cause of asthma, 485 ; hypertrophy 
of, in rickets, 256 : removal advised in 
tuberculous adenitis, 846 ; with ade- 
nitis, 839 ; membrane upon, in scarlet 
fever, 912. 

Tonsillitis, membranous (Pseudo - diph- 
theria ; streptococcus angina ; crou- 
pous tonsillitis), 295; diagnosis, 296; 
prognosis, 297 : treatment, 297 ; bron- 
cho-pneumonia in, 296 : follicular, 299 ; 
diagnosis, 300 : treatment, 300 ; in 
rheumatism, 1088 ; phlegmonous, 300 ; 
ulcero-membranous (Vincent's angina), 
298. 

Tonsillotomy, 303. 

Top-milk, 148. 

Torticollis, 678 ; congenital, 679 ; from 
cervical Pott's disease, 679, 855 ; 
from hsematoma of sterno-mastoid, 95 ; 
hysterical, 682 ; in phlegmonous ton- 
sillitis, 301 ; in retro-pharyngeal ab- 
scess, 305 ; malarial, 679 ; rheumatic, 
679 ; spasmodic, 678. \ 

Touch, when developed, 26. 



INDEX. 



Ill 



Toxaemia, in intestinal indigestion, chron- 
ic, 395 ; vomiting in, 320 ; in acute gas- 
tric indigestion, 326. 

Toxins, of diphtheria, 972, 9«)T. 

Tracheotomy, for foreign body in larynx, 
471 ; in laryngeal diphtheria, 1003 ; in 
retro-oesophageal abscess, 307. 

Trismus, in tetanus, 89. 

Trypsin, 310. 

Tubercle bacilli (see Bacillus of Tuber- 
culosis), 1021. 

Tuberculin test in herds, 139 ; in diag- 
nosis, 1047. 

Tuberculosis, 1017 ; age, 1018 ; bacillus 
of (see Bacillus op Tuberculosis). 
1017; in milk, 139; bronchial lymph 
nodes in, 1026 , clinical forms of, 
1031 ; broncho-pneumonia, 1024. 1035 ; 
chronic phthisis, 1044 ; chronic pul- 
monary, 1041 ; congenital, 1019 ; diag- 
nosis of pulmonary, 1042 ; of bron- 

- chial glands, 1044 ; general, 1031 ; 
etiology, 1017 ; following measles, 939 ; 
following pertussis, 962 ; frequency, 
1017 ; general, in infants, 1031 ; in 
older children, 1031 ; haemoptysis, 
1039 ; incipient, symptoms in,. 1031 ; 
intestines, 390, 1030 ; intra-uterine in- 
fection, 1019 ; kidney, 621, 1030 ; le- 
sions, 1022 ; mesenteric, 390 ; miliary, 
of the lungs, 1033 ; mode of infection, 
1019 ; of larynx, 469 ; of lymph nodes, 
cervical, 840 ; paths of infection, 
1021 ; pericarditis in, 577 ; physical 
signs, 1041 ; pleura in, 550, 1029 ; pre- 
disposing causes, 1018 ; prognosis, 
1049 ; prophylaxis, 1050 ; spleen, 849, 
1030 ; sputum, means of obtaining, 
1044 ; treatment, 1051 ; tuberculin 
tests, 1047 ; fever test, 1047 ; ophthal- 
mic test, 1048 ; cutaneous test, 1048 ; 
puncture test, 1048 ; inunction test, 
1048. 

Tuberculous, adenitis, 840 ; bronchial 
glands, 1027, 1044, 1046 ; meningitis, 
720 ; nephritis, 621 ; ostitis, 853 ; peri- 
carditis, 577 ; peritonitis, 447 ; pleu- 
risy, 550 ; pneumonia, 1035, 1041. 

Tumour, abdominal, in intussusception, 
411 ; in stenosis of pylorus, 315 ; cere- 
bral, 734 ; tuberculous, 1029, 1030 ; 
fatty, in cretinism, 766 ; of spinal cord, 
793 ; mediastinal, tuberculous lymph 
nodes, 1046; of spleen, 849, 1065. 

Tunica vaginalis, hydrocele of, 635. 

Turpentine stupe, preparation of, 55. 

Tympanites in acute peritonitis, 444 ; in 
intestinal indigestion, 396 ; in rick- 
ets, 255 ; in typhoid fever, 1011. 

Typhoid fever, 1009 ; bacillus of. in milk, 
140; complications and sequelae, 1013; 
diagnosis, 1014 ; etiology, 1009 ; le- 
sions, 1010 ; prognosis, 1015 ; scarla- 
tiniform erythema in, 922 ; symptoms, 
1011 ; treatment, 1016 ; Widal's test 
in, 1014. 



Ulcero-membranoua tonsillitis (Vlni 
angina) 2 ( .»s. 

Dicers, catarrhal, of Intestine, 869; fol- 
licular, of Intestine, 870; following 

tuberculous adenitis, Mi; of stomach, 

330, lo:{() ; tuberculous, Of skin. 

syphilitic, 1064 : tuberculous, of bron- 
chial lymph nodes, 1046; tuberculous, 
of Intestine, 890 : typhoid, 1010. 

Umbilical vessels, arteritis In newly born, 
82; phlebitis in newly born, 82; fistu- 
la, 111, 

Umbilicus, hemorrhage from, In newly 
born, 101; hernia of, W2 : Inflamma- 
tion of vessels in newly horn, 82 : 
treatment of suppuration, si; nun. »uis 
of, 110. 

Uraemia, acute, in scarlet fever, 920 ; in 
acute nephritis, ci.",; in chronic neph- 
ritis, 620. 

Urethra, haemorrhage from, in newly 
born, 102. 

Urethritis, 634 ; gonorrheal, 634. 

Uric acid, in early infancy. 599 : Infarc- 
tions, in kidney, (Hit ; causing hematu- 
ria, 102. 

Urine, acetone in (see Acbtonubia), <;<>4 ; 
arrest of secretion i see Amkiai, 604; 
albumin in, 600; blood in (see Hema- 
turia), 601; "brick dust" in, 599; 
composition of, 599; daily quantity of. 
598; diacetic acid in, 604 : examination 
of, 40 ; hyperacidity of, in rheumatism, 
1091 ; incontinence of, 041 ; with ade- 
noids, 291 : in diabetes, Ki'.n ; retention 
of, in myelitis, 779: in typhoid, 1013; 
in vesical calculus, 646 : indie an in 
(see Ixdicaxihia i, 603; in Infancy 
and childhood, 698; methods of col- 
lecting, 40, 698; microscopical exam- 
ination of, 59!) : physical character of, 
599; pus in (see Pyuria), 602; reac- 
tion of, 599; specific gravity of, 599; 
sugar in, 600 ; uric acid in, 599. 

Uro-genital organs, tuberculosis of, 1030. 

Uro-genital system, diseases of, 598. 

Urticaria, 890: following diphtheria 
antitoxine, 1000; in influenza. 1073; in 
intestinal indigestion, 397 : papulosa, 
890; scarlatiniform rash with, 922. 

Uvula, bifid. 2»i:: : diphtheria of, :»7 1 : 
elongation of. '_'s4 : cause of asthma, 
485; causing COUgh, 4X1; o'dema of, 
282 ; inflammation of. 282. 

Vaccination, 984; choice of lymph, 950; 

methods of, !>.">o; revaccinatlon, 949, 
Vaccinia, 948. 

Vaccines, 54. 

Vaginitis, 636; simple, 636; gonococcus 
vaginitis, 637. 

Vapour hath. 56. 

Varicella. 946 : symptoms, 946 : diagnosis, 

948; gangrenosa, 888, '.»(7; treatment, 
948. 



1112 



INDEX. 



Vegetables, allowed from third to sixth 
year. 212 ; forbidden from third to sixth 
year. 218. 

Vein, internal jugular, thrombosis of, 596; 
umbilical. 564. 

Veins, abdominal, dilated in cirrhosis of 
liver, 439; in thrombosis of vena cava, 
596. 

Vena cava, thrombosis of, 596. 

Ventricles, cardiac, relative thickness of, 
566. 

Vertigo, in cerebral abscess, 733; in cere- 
bellar tumour, 736; in functional dis- 
orders of heart, 594. 

Vesical, calculi, 646; spasm, 645. 

Vincent's angina (see Ulceromembra- 
nous Tonsillitis), 298. 

Viscera, abdominal, transposition of, 342; 
frequency of inflammations of, 41; 
haemorrhages of, in newly born. 98. 

Voice, hoarse or husky, with adenoids, 
291; nasal, with hypertrophy of ton- 
sils, 302; with adenoids, 290; in diph- 
theritic paralysis, 806. 

Volvulus, foetal, cause of malformations, 
342. 

Vomiting, 319; from overfilling the stom- 
ach, 319; in acute gastric indigestion, 
319 : in hypertrophic stenosis of pylo- 
rus, 314 ; in acute intestinal obstruction, 

319 ; in peritonitis, 320 ; in nervous dis- 
eases, 320 ; at onset of acute febrile 
disease, 320 ; from toxic substances in 
the blood, 320 ; reflex, 320 : from habit, 

320 : chronic, 320 ; of blood, in ulcer of 
stomach, 337 : stercoraceous, in intus- 
susception, 410 : cyclic. 321 ; symp- 
toms, 322 ; treatment, 324. 

Von Pirquet's test for tuberculosis, 1048. 
Vulvitis, gangrenous, 640. 



Walking, causes which prevent, 25; de- 
layed, in rickets, 255; when attempted, 
25. 

Wasting, in tuberculosis, 1039; simple 
(see Marasmus), 227. 

Water, function of, in diet, 126. 

Weaning, 174: time for, 175; indications 
for, 175; sudden, 176; percentages of 
milk required at, 191. 

Weather, hot, prophylaxis against diar- 
rhoea in, 355. 

Weight, 15; at birth, 16; curve during 
first few weeks, 16 ; curve of first year, 
17; from second to fifth year, 19; of 
older children, 19; from birth to six- 
teenth year, 20: loss of, in acute inani- 
tion, 218; stationary, indications in, 
197; symptoms of unsuccessful nursing, 
168. 

Werlhof's disease (see Purpura), 824. 

Wet dressings vs. poultices, 56. 

Wet-nurse, in acute gastro-enteric intoxi- 
cation, 358; in acute inanition, 219; se- 
lection of, 174; dangers from syphilitic, 
1067. 

Wet-nursing, 174 : vs. artificial feeding, 
165 : indications for, 166 ; disadvan- 
tages of, 166. 

Wheal, in urticaria, 890. 

Whey, 158 : wine, 158. 

White-swelling of knee, 863. 

Whooping cough (see Pertussis), 954. 

Widal's test in typhoid fever, 1014. 

Winckel's disease, 91. 

Worms, intestinal, 419; tapeworm, 420; 
roundworm, 422; threadworms. 423. 

Wrist, enlarged epiphyses in rickets, 253. 

Wry-neck (see Torticollis), 678. 

Zoolak, 157. 



(23) 



THE END 







LIBRARY OF CONGR^ 



022 216 201 4 



